Your Questions
Your Questions
Q: Dr. Eppley, I want to lessen the occipital ridge area to where it’s not as prominent.
A:Thank you for sending your picture and describing your concerns. You have correctly identified a prominent nuchal ridge. There are two ways to treat it depending upon one’s aesthetic objectives. The first is the one of which you are aware which is a bone burning reduction. This does require some release of neck muscle fibers to be able to get an adequate reduction although this has no functional issues in doing so. The other approaches to build up the indentation or the valley between the raise new core Ridge and the bone above it via a custom skull implant. This can also be very effective particularly for those may have concerns about a flatter or less projecting back of the head above it.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’d like to discuss whether a sagittal crest reduction is possible. I have a small bump on the top center of my head that gives it a slightly elongated “egg” shape. I’m generally happy with the overall shape and am only interested in a subtle reduction to create a more rounded appearance.
A:Thank you for your inquiry and sending your picture. Sagittal ridge reduction is always possible in my experience because a sagittal ridge usually represents thicker skull bone along the suture line and not thinner bone. How much reduction that can be done can be determined by a preoperative 2-D CT scan but, in my experience, always at least a modest reduction can be achieved as per the attached image. since you used the term subtle reduction that certainly seems to be possible.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am interested in facial feminization with bone work. My issues are: brow bone, orbit bone, recessed mandible, uneven face/jaw, flat midface/maxilla, low ears, floppy skin under chin, hollow temporal area, hairline, low brow, chin recess short, Skin texture/pores. Suggestions? Really look forward to hearing back.
A:Thank you for your inquiry and sending all of your pictures. Based on your areas of facial concern as well as the overall objective of female feminization I can provide the following initial comments:
1) Your brow bone protrusion is primarily in the lateral bro and not centrally. This requires hey bone burning reduction in detail of the brow which could be combined with opening up some of the lateral orbital wall as well.
2) Your recessed chin is best addressed by a sliding genioplasty as that will keep it narrow in shape but just as importantly will allow the deep labiomental fold from becoming even deeper…. which is what will happen with an implant. The sliding angioplasty will also best address the loose skin under the chin which gets eliminated as the chin bone moves forward.
3) The flat midface can be addressed by paranasal – maxillary implant augmentation.
4) The low set ears cannot really be repositioned higher. I’ve tried to do that many times and have never found a successful technique to do so. However the earlobe can be reduced and that will create the perception of a less long or higher positioned ear to a minor degree.
5) you have the classic female temporal hollowing which is best treated by a style II 4 mm extended temporal implant.
6) You have mentioned the hairline with a low brow and I am going to assume this means a brow lift would be favorable. It is unclear to me whether you want to keep the hair line at its current position or have a higher or lower. That is important information to know is that will influence how the browlift is done.
7) The only effective way to decreased pore size in combination with improving skin texture is laser resurfacing.
These are some of my initial comments and I have done some initial imaging in the left oblique view to reflect some of these potential changes.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had 20cc testicoe implants put in a year ago but would like to have larger implants put in as these feel too small.
A: At a 20cc testicle implant size that is 4.0 implants. If one is interested in a visible size increased the general rule is that it needs to be at least 30% or more increase in volume. Thus at a minimum you would need to change to a 5.0 size which has a total volume of 40 cc. That would still fall within the standard testicle implant size options. Obviously you can go bigger, which is a personal choice, but anything over 5.0 requires a custom implant design.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am very interested in the temporal bone reduction surgery that Dr. Eppley performs. I would like to ask a few questions before scheduling a consultation: 1. Is it possible to combine bone reduction with a partial reduction/removal of the temporal muscle if needed for a slimmer head shape? If yes, what are the additional risks? 2. How many cases of temporal bone reduction has Dr. Eppley performed, and are there any before/after examples or references available? 3. What is the usual recovery timeline (return to daily activities, exercise, sports)? 4. For an international patient, how long should I plan to stay in the U.S. after surgery for safe follow-up? Thank you very much for your time and assistance. I look forward to your reply
A:In answer to your temporal reduction surgery questions:
1) the primary effects of the procedure are achieved by muscle removal and repositioning, not bone removal. The temporal bone is very thin and will yield little in terms of visible reduction. This is why bone reduction as rarely part of the surgery.
2) I have performed hundreds of temporal reduction surgeries. You can find many examples if you search the topic on either of these two websites, www.exploreplasticsurgery.com placing the term Temporal Reduction in the search box or www.eppleyplasticsurgery.com n the photo gallery.
3) recovery from temporal reduction surgery is fairly quick and is largely just due to the swelling most of which has gone down in 10 to 14 days. Otherwise there are no postoperative physical restrictions
4) most patients return home in 1 to 2 days after the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I’m interested in exploring a revision for my genioplasty. I had the procedure five years ago and I feel like I’m not completely happy with the results. Specifically, I feel like my chin looks a bit too projected and masculine, and I especially notice it when I smile. I’d like to understand what options might be available for a revision, or whether a chin implant might be something to consider. I’d appreciate any guidance or next steps. Thank you
A:When it comes to a sliding genioplasty that has too strong of a chin augmentation effect one has to look at a reductive approach for which an implant would not be effective in that regard. This can either be done by setting back the sliding genioplasty a bit or using a submental approach from below to shave down the projection as well as narrow the sides and then remove any soft tissue chin pad excess that remains.
In looking at all of your pictures, even though I have no idea as to what you looked like originally, I think it is a tough decision in deciding to do anything. I see what you are seeing and I think the projection and masculine aspects of it are slight in their excess. As a result I think it is a hard decision to try to improve these concerns. I always worry about is the solution and a case like yours greater than that of the problems. As you have just learned from this sliding genioplasty every surgical procedure has its downsides and no procedure is perfect.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I saw Dr Eppley respond to a question regarding muscle displacement after a jaw jaw implant and I’ve been told that might have been what happened to me, so perhaps Dr Eppley can help me!
I had surgery with an oral surgeon and he placed two gore-tex gonial implants in the back of my jaw and two near my chin. I ended up asking for the gonial to be removed as I did not like the look. Afterwards I unfortunately noticed strange differences to my face that I didn’t understand. One was that I had volume loss on the back sides of my back jaw angle. At first I thought that I had bone loss from the surgery. Multiple other surgical consults have recommended an oral appliance for treatment of it.
A:Indeed what you have described appears to be the correct diagnosis, masseter muscle dehiscence, after the placement of jaw angle implants. Such a postoperative sequelae is not completely rare if the surgeon is not careful about how to elevate the insertion of the masseter muscle in the placement of jaw angle implants. I have seen many masseter muscles dehiscences as well as having treated them. That being said you cannot reposition the muscle is that is not usually a successful reconstructive surgery. Once the muscle has lost its insertion its fibers are shortened and rarely can they brought back to length. But even if they could most patients would not prefer an incision behind the jaw angles to do so. Does any treatment for it becomes more of an effort of camouflage rather than actually addressing the anatomic nature of it. Most commonly it can be treated by Botox injections to the elevated muscle to reduce its prominent and/or combined with injectable fillers or fat injections to the now deficient jaw angle area. In my extensive experience in treating it I usually find it most effectively treated by a soft tissue jaw angle implants placed 1 cm incision behind the jaw angles which heals well.
The one thing I know for certain, as you have already mentioned, is that no oral device is going to solve or improve this anatomic muscle problem.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I would like to discuss the benefit and risk involved with shaving down an existing Medpor chin implant. I’ve been informed that removing it to replace with a custom implant, can cause tissue damage. The implant has been in place for about 1 year. I’ve also been informed that shaving down the medpor implant in place could cause damage to surrounding tissue. The current Medpor implant is too large and square, and the lateral wings are palpable which I don’t like. The current projection of 3mm is OK for my face. I found an ideal custom chin implant without lateral wings, on your website.
A:As a general rule don’t ever try to shave down a Medpor chin implant in place. That is not going to work well and it is a flawed concept. Given the nature of your concerns with your current implant shape the most effective strategy s to remove it in its entirety and replace it with an improved implant design. I don’t know where the concept of concerns about tissue damage come from as they are completely irrelevant. Scar will exist in and around the implant and manipulation of that scar is just part of the surgery.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m just reaching out to see if there will ever be the possibility of such a surgery being done on a FTM transsexual, since from what I can tell most surgeons would be against it as it’s usually unadvisable to meddle with the hip joint for “cosmetic” purposes. Would it be possible to find someone willing to work with me on surgically reducing the width of the lower part of the hip? What changes to my bone structure would be necessary for this problem to be fixed? My hips are always just a bit too wide at the base and it tends to give me an inherently more feminine shape than if they were more straight. It would be more acceptable if my shoulders were wider, but my shoulders are also quite narrow for a male. I’m already working out and trying to bulk up my upper body, but I can tell that even if I manage to lessen my dysphoria further with CBT and other therapy in general, my hip structure will always be a point of pain for me. I’ve attached the pelvis X-ray for reference if that would help. Is there any chance that needing surgery for this in the future would affect my hip breadth, be it positively or negatively? Thank you for any insight you can offer on this matter. I look forward to your response.
A:You are referring to reduction of the lateral prominence of the greater trochanter of the femur. This is an area of the femur where a number of musculoligamentous attachments are. Reduction of this bony prominence requires elevating these attachments which have unknown and potentially adverse short and long-term complications. Most pertinently it may lead to chronic pain and difficulty with walking. It is also possible that it may lead to long-term osteoarthritis of the femur. As a result it is understandable why surgeons are reluctant for aesthetic purposes to risk this type of complication. It is also possible that such surgery may only create some short-term discomfort and in the long-term be fine. These outcomes and risks are unknown.
That being said I’ve thought about the surgery and patient selection would be of critical importance if it were to ever be done. The patient should be thin where the bony prominence is very palpable and the amount of reduction needed not be excessive. The above unknown risks remain even with good patient selection.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Hi. I am a 21 year old male. I have a small head of 51cm as I recently shaved my head. I am perfectly healthy. My father also had a small head. I wanted to ask If there is a way to increase it and if so to how much extent? Can I have a normal male head? I would be extremely grateful for the response.
A:Skull augmentation is largely about Increasing specific areas of the skull rather than an overall head size increase. Augmenting certain areas of the head can make it look bigger but if you’re going to use circumferential head measurements as a measure of success then you are going to be disappointed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I’m interested in the thigh implant procedure. I have a small frame and have always hated my small thighs. I have a big but and my small legs make it look very unnatural. The last two images are what I am looking to achieve.
A:Thank you for your inquiry and sending your pictures. On my initial reaction to it I thought initially that this would not be a remotely achievable outcome. However upon closer evaluation comparing your thighs in a side-by-side fashion to the ideal images it became more apparent that the differences is in the anterolateral thigh which is exactly the area thigh implants augment as per the attached diagram as drawn on your thighs. This does not mean that you’re going to get that exact outcome as it is a magnanimous change but at least the concept of implants in this location will improve your current thigh-buttock disproportion.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I’m wondering if you are able to reduce the width of my hard upper ribs? Particularly the 10-7. Would shortening those through bone cuts be adequate in not just narrowing the sides but also reducing front to back width? Are you able to reduce the width of the from to back? I am particularly concerned about the bulkiness of my rib cage when see from the side.
I’m quite happy with my waist line. For me it’s primarily the bulkiness of my upper body I am quite self conscious about.
The flair of my ribs is really upsetting me.
A:Thank you for your inquiry and sending your pictures. When it comes to the side profile view of your chest there are two issues which are related but would be treated differently. The first is that you have a modest amount of subcostal flare which is due to the cartilaginous shape of ribs 8 and 9 which is reduced by removal of the anterior part of rib #9 and shaving of the prominent part of rib #8.
But I don’t think that is your major concern which appears to be the distance from the front to the back of the rib cage as illustrated in the attached picture. You have correctly surmised that removing sections of Rib 8, 9 and 10 and plating them back together on each side does reduce the front to back distance. The only question is how much and whether the reduction gained is worth the surgical effort.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, my head is bigger and wider than it looks in a picture and it is square. I want it to be oval. Is it possible to make a skull oval and reduce the head width?
A:Thank you for your inquiry and sending your pictures. If I am interpreting your objective of making the frontal view of the head shaped less square and more oval I have attached a diagram of what I think you want to accomplish. The square shape of the head is largely controlled by the bony temporal line and the upper temporal muscle. These can certainly be reduced to decrease the squareness of the head shape and make it more oval.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have a question. A different procedure I’m interested in is rib remodeling as opposed to rib removal. I believe it is known colloquially as ribxcar. I’m specifically interested in going up to the 8th rib, but I know this requires expertise with this kind of procedure. Does Dr. Eppley perform this kind of procedure, or does he only do rib removal?
A:I have performed both rib removal and rib fracture techniques although by far most people come to me for the rib removal method. The rib fracture method is a simpler technique that relies heavily on months of postoperative compression to achieve its effects. I have not found the rib fracture method to have less of a recovery and and in some cases the recovery is more painful with fracturing than removal. Rib fracturing requires the bone to heal and develop bony consolidation while rib removal involves soft tissue (muscle) recovery and not bone.
The rib fracture technique only applies to ribs 10, 11 and 12 because they have unattached ends. Fracturing ribs 8 and 9 will be of no benefit since they have stable front and back attachments and thus are not capable of collapsing by being fractured. Regardless of the rib method used ribs 8 and 9 need to have a bone section removed and then the two ends put together with plates and screws to achieve any narrowing reduction.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I had cheek implant surgery with Dr Eppley many years ago, and I have a question if the Dr used any metal or screws in my face during the surgery to hold the implants in place. Im writing because im going to have a MRI Scan soon and i need to know if there was any metal, screws, or other matieral atached other then the implants? It would be very helpfull too know this.. Thanks alot for your help!
A: I can not recall the specifics of any surgery from 11 years ago. But since I always use screws for facial implant fixation I will assume that was done in your case. Such medical-grade facial screws since 1991 have been composed of titanium, a non-ferromagnetic metal, they are perfectly safe for undergoing MRIs.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, I was wondering if it’s possible, and safe (low risk for botching/complications), to widen the alar base of the nose. It really adds a strong touch of masculinity that my face is missing. In particular by trying out morphs in a photo editing program, the alar base alone being made wider makes the biggest difference.
A: As long as the nostril widening was not more than a few millimeters that could be done without undue scarring.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, I have a mild case of Cutis Verticis Gyrata and, while researching possible treatments, I found your article “Plastic Surgery Case Study – The Treatment of Scalp Cutis Verticis Gyrata with Subgaleal Release and Fat Grafting” on the website exploreplasticsurgery. I believe my situation is similar to the patient presented in your article, and after consulting with a plastic surgeon, she was enthusiastic about the procedure. However, since it is not widely reported, she had some doubts, especially regarding the step of releasing the scalp before performing fat grafting. She expressed concern about the arteries in that region. I would like to clarify this point with you and, if you allow, I would like my doctor to contact you directly so she can ask further questions and benefit from your expertise with this procedure, as I intend to undergo the surgery. CVG bothers me a lot. Attached are photos of my scalp. I would also like to know if the procedure proved effective in terms of fat resorption, and whether you have performed other similar cases.
A: As long as the CVG is not too advanced with deep linear V shaped scalp lines releases with fat grafting will provide improvement in its appearance in my experience.
If your surgeon is questioning the arteries in the scalp’ with a release this tells me they have little scalp surgery experience.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, big fan of your work. Im looking to get custom jaw and cheek implants, and was looking to replicate this jaw/cheek structure from this male model. Have you designed one that closely resembles his features before? Same cheekbones and that same type of sharp jaw angle.
I’ve seen many custom cheek and jaw implant designs before but curious to see which one directly resembles this model’s approximate structure.
Here is my most recent CT scan, i have standard jaw implants and a chin implant
Im going to get a sliding genioplasty, but in terms of jaw and cheek implant design, i was wondering if doctor Eppley designed ones closest to the model before?
A: You have a completely inaccurate concept of how custom facial implants are designed. No one knows the skeletal shape of these model faces or what implant designs can come close to creating them. The only way to know with any accuracy is to take a 3D CT scan of their face and overlay it on a 3D CT scan of your face to show the bone shape differences. Short of that method custom implant designing is a best guess estimate….and even this assumes you have the right soft tissue thicknesses where such implants can show through enough for their full effect to be seen.
Dr. Barry Eppley
World Renowned Plastic Surgeon
Q: Dr. Eppley, How long does it take to get custom facial implants made?
A: The rate limiting step in any surgical procedure that includes custom designed implants is the time it takes to go through the design and manufacturing process of them. This is usually around two to three months from when the 3-D CT scan is received on which the implants are designed.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I have been struggling with what i think is Parry Romberg on both sides of my face for the past year. It has been mentally and emotionally draining and is affecting my everyday life. nPlease help!!
A: Thank you for sending your pictures. While you do have a grade III or IV facial lipoatrophy condition this is definitely not Parry Romberg syndrome. Parry Romberg syndrome follows the distribution of the trigeminal nerve and has a very linear pattern of atrophy. It also tends to only occur on one side. of the face. What you have is an overall lipoatrophy which has affected all of the fat compartments from the temporal down to the buccal spaces resulting in this classic gaunt facial appearance. Once the fat is lost it is lost and the body is not going to restore it. This is a reflection of a more systemic cause such as significant weight-loss, certain medications and various medical conditions.
Regardless of the cause there’re various methods to treat this type of facial lipoatrophy. The most obvious treatment is that of fat injections into the temporal and submalar/lateral areas of the face provided one has enough donor sites to harvest the needed fat. One could argue how well will fat survive in areas where fat originally was and disappeared. That is a logical debate but the benefit of fat injections is that they are autologous and have no known medical side effects…. not because it is the most assured treatment. But it remains as a first-line treatment for those patients who are so motivated. The alternative are temporal and submalar cheek implants which provide a more assured and sustained result. These will do well in those two major areas but will not provide any augmentation in the lower facial areas from the mouth along back to the ear. This area can be concomitantly treated with either fat injections or there are various tissue banks tissue grafts and even thin implants that can be placed into this soft tissue area.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I got custom infraorbital implants to correct my undereye hollowing which it did not do. I have attached the implant design file.
A:Just because implants were made custom does not mean they are going to create the desired effect. Besides accurate placement the other major component of an aesthetic outcome with custom implants is their design in terms of surface area coverage and various thicknesses throughout the implant. My first question when I see someone who has had custom implants that did not create the desired shape or created and the fact that they did not anticipate is…. what was the basis of this implant design? Why was this implant designed this way and what were the original objectives?
As I am not privy to all of that prior information I can only look at the current problem… which is persistent under eye hollowing. While this implant design does cross the infraorbital area it only provides horizontal infraorbital rim augmentation which will either maintain or worsen the presence of any pre-existing under eye hollowing. To properly treat under eye hollowing the infraorbital rim area must be augmented both vertically and horizontally known as saddling the rim. This implant design does not do so and even though it provides infraorbital rim augmentation it never had a chance to improve under eye hollowing. This is a flawed implant design to achieve that effect. This undoubtably was done by a surgeon who has never used implants to improve under eye hollowing and tried to do so with an implant design placed intraorally. The only way to successfully treat under eye hollering is an implant design that saddles the rim and is placed through a lower eyelid incision.
Given the benefits that your current implants provided in the cheek area my tendency would be to design new implants that sit on top and round these existing implants place they will lower eyelid incision.. Stacking implants on top of each other has its potential disadvantages but in your case may be the most appropriate approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I underwent a chin implant five weeks ago and am unhappy with the result. It is too wide and blocky in appearance. I think I should switch to a sliding genioplasty. I am also concerned about long term bone erosion with a chin implant. What do you think?
A:Thank you for your very detailed inquiry. To which I can make the following general statements:
First you are only five weeks after your surgery which is way too early to make definitive judgments about the final results and what you may or may not do. I do not recommend nor do I operate on patients before their fourth month after surgery as is that is when the true effects of the final bits of swelling and shrink wrap effective the soft tissues have occurred.
Second I would be very cautious about making a radical change in your chin augmentation approach when the changes you are seeking may well be able to be achieved by an implant. Every operation, chin implant or sliding genioplasty, has its issues. There is no perfect operation whether it be chin argumentation or any other surgery…. particularly if one is going to evaluate the results under the microscope so to speak. The only valid reason in my opinion that you would switch to a sliding genioplasty, after the requisite four month postoperative period. Is that you have decided that you simply do not want any foreign material in your body. If that is the issue then whatever the aesthetic trade-offs are for a sliding genioplasty become irrelevant. The concerns that you have pointed out about a chin implant, soft tissue compression and so-called bone erosion, our biologic fallacies. They are commonly believed even among surgeons but they are simply incorrect about their understanding of what they are seeing. Implants do not cause bone erosion, they can cause implant settling which is a passive self-limiting reaction to the tissues to the interposition of an implant that violates the natural biologic boundaries of the soft tissues. This occurs in all implants throughout the body that’s not unique to the chin. But because of the frequency of dental x-rays it is the most observed phenomenon of all implants in the body. Be aware that even the sliding genioplasty has a response to the pressure displacement of the overlying soft tissue caused by the new bone position…. which means the moved chin bone will change its anterior shape often losing about a millimeter of projection over time. Yet nobody calls this well-known phenomenon bony erosion. It is just another example, in this case an autologous surgery, of biologic adaptation of a bone shape that has changed anatomic position from what it was developed to be.
Third I would also caution any patient how about trying to take an overall good result and trying to make it ideal. As I often tell patients as well as other surgeons secondary or revision on surgery always presents the opportunity to make something worse or develop a complication the patient did not previously have. Just because your first surgery was uncomplicated and healed well is no guarantee that whatever you do the next time will do as well. This does not mean that one should never have secondary surgery within initially satisfactory result just let one needs to be mindful of the potential risk and fully understand what the trade-offs are.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Based on the photos I sent, I am concerned about the overall width of my head, particularly the prominent temporal areas and the flat back (occiput). I would like to know if my case could be addressed through temporal reduction (muscle or bone) and/or an occipital implant to balance the proportions. Could you please let me know if these procedures would be appropriate for me? Thank you very much for your time and evaluation.
A:Thank you for your inquiry and sending your pictures. To make sure I have correctly identified your concerns based on the description I have attached your pictures with the areas highlighted but I believe to which you refer. The most straightforward to her correct is that of the occipital deficiency as a custom skull implant will provide an immediate and effective resolution to that problem. From my head widening standpoint you have a high temporal widening which is probably reflective of a boned problem more than that of the muscle. Is the temporal muscle originates from the bony temporal line in that area it usually is thinner than that which lies below it. This means that traditional temporal reduction surgery, which is muscle removal alone, will provide some improvement but probably not optimal. While it would be more ideal to reduce the bone in that area as well, which can be done, I would be concerned about the incisional access to do so given the short hair that you have in that area. Meaning I am leery about the scar trade-off to obtain that additional level of improvement.
As a result, if it were me, I would get the cccipital augmentation and the traditional temple muscle remvoal and then see the level of motivation based on the improvement obtained about whether bony temporal reduction would secondarily be considered.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I’ve heard a lot of great things about your work, and I wanted to reach out to you since I believe you are the best professional to assist me in this matter.
On the top left side of my head, I have a medium-sized indentation. It’s not a large area, but it makes a noticeable difference in how my head looks. What I’d really like is to add some volume there so the contour appears more even.
Unfortunately, about three years ago I found a physician and tried the silicone 1000 microdroplet technique, which I now feel may not have been my best decision. I don’t believe I have much of it there, but after the second treatment, the doctor told me it wouldn’t be possible to safely achieve the fullness I wanted that way. I also understand this could present complications in the future. Since then, I’ve been exploring other options.
From my research, I’ve considered two possibilities:
- A custom implant, placed through a hairline incision, possibly with removal of some silicone if that’s feasible.
- Fat grafting after removing some silicone, though I feel an implant might be more reliable.
I realize there are risks and limitations, especially with the presence of silicone, which is why I wanted to ask your opinion. I even sketched a quick graphic and included some photos.
I would really value your thoughts on whether something like this could work, or if there’s another solution you’d recommend and could assist me with.
A:Thank you for your detailed inquiry and sending your pictures to which I can say the following:
1) Your left upper temporal deficiency is clear in your pictures. Whether that represents a bone contour deficiency or a difference in the muscle between the two sides cannot be determined by a picture alone. But regardless of the actual anatomic nature of the deficiency the best procedure would be an under the muscle bone based implant to augment it. That would have the least risk of any short term or long-term implant related issues. What the dimensions of that implant would be would be able to be determined by a 3-D CT scan IF it is a bone base deficiency… Which I suspect that it is.
2) in a bone based implant under the temporal muscle the prior silicon injections would have no bearing or adverse effect. As you have mentioned the injected volume is likely very small and would probably not be an issue even if some form of implant augmentation was done on top of the muscle as opposed to under it.
What I would initially recommend is to get a 3-D skull CT scan and really evaluate the anatomic nature of the problem. That will help guide what treatment approach would be most effective.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q; Dr. Eppley, I am very interested in learning more about the Iliac Crest Reduction procedure that your clinic offers. I would greatly appreciate it if you could provide me with information regarding the following:
- The approximate cost of the surgery.
- What is typically included in the quoted price (surgeon’s fee, anesthesia, hospital stay, post-operative care, etc.).
- The expected recovery time and any lifestyle restrictions following the procedure.
- Whether this surgery can be combined with other contouring procedures (such as liposuction or body sculpting).
- Potential risks or limitations that patients should be aware of before undergoing this operation.
As I am located outside of the United States, I would also like to know if you offer virtual consultations for international patients.
Thank you very much for your time and assistance. I look forward to your reply.
A: In answer to your questions about iliac crest reduction;
1) Most patients will experience some initial walking discomfort due to the trauma to the TFL fascia along the iliac crest. But this is self-limiting and usually resolves within 7 to 10 days after the surgery.
2) Iliac crest reduction can be combined any other body contouring procedure.
3) Ither than the fine line incision/scar to do the surgery I think the biggest potential limitation is how much bone can be reduced and whether this will match what the patient’s aesthetic objectives are. This is an issue which should be determined preoperatively and not decided postoperatively. To do so I would just need to see some pictures of your hips as well as an understanding of what your surgical objectives are.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, Thank you very much for your detailed explanation and for clarifying the situation with my current Medpor cheek implants. Based on this information, I would like to kindly ask:
Given the specific models, what options would you recommend in my case?
Do you think it is possible to design and place new, better-fitting implants that could solve the current problems?
My main concern is to understand what is realistically achievable and whether you feel confident that you could help me in this situation.
Thank you again for your time and guidance. I look forward to your opinion.
A:Thank you for sending your additional information. These are classic Medpor inferior orbital rim implants, which only come in 3 mms of horizontal projection, that have been placed intraorally with double screw fixation on the side as seen in your 3-D CT scan. As I have seen many times for these implants they create both a ledge and do not improve or increase under eye hollowing. As I probably previously stated you can’t simply add horizontal augmentation to the infraorbital area, a 2-D solution, for undereye hollowing, which is a 3-D bony problem.
To provide improvement of the result that you currently have these implants need to be replaced with custom infraorbital rim-malar implants that provide a 3-D augmentative effect. These are placed through the lower eyelid which is a direct approach to implant placement and being able to place an implant that actually saddles the rin. Your existing Medpor implants will need to be removed exactly the same way in which they were placed, intraorally, as the screws have been angled in from that direction and cannot be removed from a superior eyelid approach.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I understand Dr. Eppley has performed dermal fat injections to treat coccydynia. I recently had this procedure done and for about 4 weeks it completely eliminated my tailbone pain. But the pain returned not long afterwards and now my pain is the same as it was before surgery. My plastic surgeon is attempting the surgery again in a few weeks. My question is, does Dr. Eppley have a list of post op recommendations to increase the success of dermal fat injections? I was told I can exercise fully after 4 weeks, including using weights and I wonder if that was detrimental to the surgery.
A:I don’t do fat injections for coccydynia and have never have for the very reason you have experienced….100% of the injected fat will resorb and the benefits will be very temporary (4 to 6 weeks). I do dermal-fat grafts not injections. This is the placement of a solid fat graft through an open incision with or without some tailbone bony reduction. This type of solid fat graft has a much higher incidence of survival and is far superior is pressure area lie the coccyx.
FYI Fat injections (liquid) is not the same as a solid fat graft.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,Is subcostal rib margin shaving/reduction completely put of question for a kidney pancreas transplant patient who is 5 years in and has never had an episode of rejection? I imagine rib remodeling is because the patient needs to wear a corset for months which i would think probably puts pressure on the transplanted organs.
A:Your supposition about not doing rib reduction in the kidney-pancreas transplant patients is correct. This would not be a good benefit to risk ratio.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley, I am contacting you now because I have come across your case report about correction of sagging buttocks: https://exploreplasticsurgery.com/plastic-surgery-case-study-long-term-persistence-of-the-infragluteal-fold-in-lower-buttock-lifts/
I have one patient with a double fold after liposuction in the dorsal thigh area about 18 months ago. She has tried thread lift, fillers and some skin tightening at other clinics with no result. We have been discussion a surgical procedure similar to what you have described in your case report.
In my experience it is always difficult to elevate tissues against gravity long-term, and I have told her that there is a risk that the native gluteal fold with time will appear lowered even though if we can correct the double fold. However, you seem to have overcome this; your results are not only nice but also are long-lasting.
Therefore, I wonder if you could elaborate a bit on which sutures that you use (permanent?), and if there are any other pearls/caveats that could be useful to know.
A:One of the most common reasons for lower buttock lift surgery is when liposuction is done for the banana roll deformity. Having done many lower buttock lift surgeries I have never found descent of the re-created fold to be a problem.. Technically the excision creates the elevation of the fold and efforts to deliberately lift the fold are not really needed. By definition it is the overhang that is being removed and the excision merely re-establishes the original fold which was not visible because of the overhang. This is what you see when liposuction suction has created the problem which is really a form of pseudo ptosis. Why all of the other trial procedures do not work is because they simply cannot get rid of what is a tissue excess. That concept of a lift through threadlifts and skin tightening is an erroneous concept for the problem. You can’t lift or skin tighten away tissue excess
With the excision I secure the dermal edges of the excision down to the gluteal fascia. I don’t use permanent sutures, rather In use long lasting resorbable sutures.
The biggest postoperative problem i lower body lifts, as defined by the need for revision on surgery, is not the descent of the fold but some hypertrophic scarring which may require a secondary scar revision.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
Q: Dr. Eppley,I am wondering what can be done regarding a protrusion at the top of my head where I believe the coronal sutures come together(?!).the protrusion is like a line that goes from left to right, not front to back. It is a pronounced raised line that I worry about for aesthetic reasons.
A:You are likely referring to a raised coronal suture line which can cause a transverse protrusion. If the bone is thick enough it can be reduced by burring. A preoperative CT scan is done to make that determination.
Dr. Barry Eppley
World-Renowned Plastic Surgeon
