Your Questions

Q: Dr. Eppley, I have questions regarding forehead reduction. I have very prominent frontal bossing. I would like to only do a forehead reduction but i was wondering if it would can look botched by such a procedure. Can you look at my forehead and tell me if a forehead reduction would solve my problem. I don’t want to shorten my forehead, as i love big foreheads, but I’m insecure about it being protruding.

A:Thank you for your inquiry and sending your pictures. The only effective treatment for frontal bossing reduction is bone shaving. The question with bone shaving is how thick is the fore head bone and how much reduction to be achieved. While you have expressed concerns about what I would call overcorrection, a.k.a. what you call a botched forehead, the reality is overcorrection is never possible in the fore head and a female because of the very thin bone. Conversely it is the opposite concern of which one should be aware, meaning can you do enough bone reduction based on the bone thickness to make the procedure worthwhile. In that regard I have attached some imaging of the most amount of frontal bossing reduction I think is possible. The purpose of the imaging is to help you answer the question if that was the result you achieved would that be enough of a reduction?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My midface is flat and downwards and my eyes are prominent having a huge lower scleral exposure.

A:You have classic negative orbital vector which means the infraorbital mailer complex of your upper mid face is horizontally deficient. This is best addressed by a custom made infraorbital-malar implant with lower eyelid lengthening with spacer grafts and a canthoplasty. Each one of these three surgical components not only provides horizontal augmentation but also serves to vertical lengthen and drive up the position of the lower eyelid to decrease the amount of scleral show.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m messaging you because for some time I’ve been unhappy with my facial symmetry but I can’t quite put a finger on what it is. I think it’s a combination of the dynamics between my nose, my eyes and my eyes brows being uneven but I’m not exactly sure. I have messaged you in the past with a couple of concerns that I thought might have been the problem I was unhappy with but I don’t think those were the issues since I couldn’t quite articulate what It was I was unhappy with. Long story short, rather than coming up with different “hypothesis” as to what I think is wrong, I’ve uploaded some photos and if you can, I’d like you to tell me what you think it is that I am seeing or what is asymmetric that is making me unhappy and could stand to be corrected. I definitely think it’s something to do with my nose, eyebrows and eyes. My nose I feel tilts to one side, one eyebrow is lower than the other and one eye appears opened wider than the other.

A:Your facial asymmetry is largely around the eyes, particular the right eye which is set back and a bit lower than the left side. In essence you have a right periorbital facial asymmetry. Such facial asymmetry’s are very apparent to people, even if it is minor in magnitude, because it is the first thing that you see and look at the most on your face.

That being said,  however, there is no good surgical procedure to make any improvement with this type of periorbital asymmetry. Meaning surgery is just as likely to make it worse as it is to have a chance to make it better.

Dr. Barry Eppley

Q: Dr. Eppley ,I suffer from a flat, even recessed, maxilla and would most likely benefit more from jaw surgery, however, my desired results could also be achieved through implants and I’d rather take the latter route as jaw surgery is way too extreme for my liking. As of now, I am definitely most interested in the paranasal implants as it is my main concern (nasolabial folds), but I am also interested in the premaxillary implant as well. I am not looking for an extreme change, but I would like an overall projection in the mid face, specifically around the base of the nose. The results I am hoping to achieve is a slightly lifted nose as well as volume in the upper cheeks right below the orbitals. Is this possible? Some concerns of mine include the upper teeth “disappearing” when smiling and talking. This is already something I have issues with because of my deep bite and would rather not emphasize it. This also includes the change of the smile. Another concern is with the implants moving, is that avoidable with screw ins? I have attached a before picture of my profile and an edited after picture of the results I am hope to achieve.

A: Thank you for your inquiry and sending your pictures. In looking at your pictures certainly jaw surgery would be too radical and based on what I believe your objectives to be would also not achieve that outcome in the way that you desire. Therefore implants are a reasonable consideration. In looking at your imaged objectives both pictures appear to be the same so it is not yet clear to me as to your exact objectives. That being said I can make the following paranasal implant comments:

1) I would be cautious about the premaxillary component as that will open up your nasolabial angle which may create an undesired effect in your case. Also when you cross the premaxillary area that increases the risk of affecting your smile and in particular having less visible to tooth show when smiling. Premaxillary augmentation should only be down when there is a clear premaxillary retrusion with a decreased nasolabial angle.

2) As you start to mention increased volume in the upper cheek area this is really beyond what a standard paranasal implant is designed to do. Such an augmentation effect requires a custom implant design to do so.

3) Implants don’t move or migrate after surgery, this is a common perceived fallacy. The surgeon and the patient may notice that the implants have a non-desired position two or three months after surgery when all the swelling goes down but this is reflective of placement not migration. The outcome of any facial implant surgery takes 2 to 3 months to fully see. Ultimately implant position is firmly established by the encapsulation scar process within six weeks after the surgery. Screws merely hold implants into the desired if the implant shape and the underlying bone onto which it is placed is not perfectly matched. Then once the scar process has occurred the screws serve no purpose. As it turns out the standard ePTFE paranasal implants have a  microporous texture which allows rapid tissue ingrowth and screws are generally not needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I took some pics where you can kind of see the slight difference in my jaw angle implants. I don’t think I can handle surgery right now, but in the future, do you think he could make it even for a fair price. the side with the added length is good and I like that side. lol it’s not that noticeable but I’m a perfectionist if you know what I mean.

A:Thank you for the long-term follow-up to which I can make the following comments:

1) I never consider revision and its potential success in facial implants until I see a postoperative 3-D CT scan to know for certain where the implants actually are and what type of changes maybe needed to improve their position.

2) I would be very cautious about being a perfectionist in the jaw angle area. Due to the intraoral approach and the increased risk of infection as well as masseteric muscle dehiscence, both of which you have never experienced but may occur in secondary surgery, there is always the chance in the pursuit of perfection to end up with a postoperative complication that is greater than the original problem in which the surgery was designed to treat. That does not mean one should never do revisional  surgery in jaw angle implants just that you need to be mindful that the risk:benefit ratio is significantly increased in the more times you do the surgery. Another words the benefits are much less than the first surgery but the risk are much greater than the first surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My question is about ribxcar vs rib removal with the Latismus Dorsi muscle resection you do. I have scoliosis and my left side has much more muscle while the right curve is concave giving me a great curve on the right side but straight on the left. I’m actually seeing better results from the ribxcar remodeling procedure than the actual rib removal (which is confusing to me) but I’m thinking for me the problem is actually more the muscle on the left side. I’m wondering a) how is the ribxcar remodeling procedure yielding average 3-4 in waist reduction while rib removal seems to have very minimal change? And what is the recovery like for LD muscle resection? I’m also concerned that without that muscle I’ll have back problems since that is how my body compensates for the scoliosis. And if the muscle would just grow back. I’ve attached a photo of my torso as well as an xray of my scoliosis curve for reference Thank you!!!

A:I do not know where you’re getting your information that RibXcar is more effective than Rib Removal. In almost every case that I have seen RibXcar is always done in combination with other body contouring procedures particularly tummy tucks or BBL surgery. I have yet to see a case of RibXcar, and I have seen many, where it is done in complete isolation without any other associated body contouring procedures… so it never fully known which of the procedures had the actual effect or which one of them made the greatest contribution to the outcome. Conversely Rib Removal is almost always done as an isolated procedure. Thus it is virtually impossible to compare the effectiveness of the two procedures as they are usually done under different circumstances. (one is an ancillary procedure while the other is a prinmary procedure)

That being said improving the effects of scoliosis on torso shape/symmetry is always challenging. Without a 3-D CT scan of the rib cage it is hard to know what is creating the asymmetry although it almost always a combination of rib bone and muscle. Your plain rib cage x-ray shows the asymmetry between the two lower rib cage levels so you do know that there is a bony component. Whether the muscle is making any contribution to it can only be speculated as it would really require a 3-D MRI to fully see the shape of the LD muscle on both sides. FYI LD muscle resection is not associated with any functional limitations or causing back pain.

But looking at your body picture that you sent you are exactly the type of patient RibXcar may be considered when the torso asymmetry is more modest in magnitude.  Because it leaves minimal scarring and is a less invasive operation it is not unreasonable to first try some osteotomies of the lower ribcage (10 and 11) to see if that makes an improvement. So you can see RibXcar is not really chosen because it is the most effective procedure but given the scope of the problem a less invasive effort may be more appealing to try first. Remember, however, any success with RibXcar is critically dependent on three months of strict corset wear. It is not the operation that creates the effect it is that the operation allows postoperative molding to be done which is what creates the effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a 70 year old man interested in the least expensive method to reduce Turkey Neck. (wattlectomy)? Thanks

A: Thank you for sending your pictures. There is no question that the most surgically effective, quickest recovery and most economically efficient procedure for a turkey neck is the direct necklift. While this has all of the associated benefits over that of a traditional lower face/neck lift the one trade-off or liability is the final line scar down the center of the neck. So any patient being considered for a direct necklift has to be especially aware of this aesthetic trade-off. For this reason the direct necklace does almost exclusively used for a limited number of older man above the age of 65 who is willing to except this trade-off as opposed to the more traditional lower facelift procedure which avoids the neck scar but has a much higher cost and recovery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a consultation for a unilateral cheekbone implant revision. I currently have Medpor cheek implants on both sides. I am very happy with the appearance of one side, but the other side has a visible asymmetry in size/projection that I would like to correct. In the photos I am sending, there is an image with a red arrow pointing toward the cheekbone area I would like to fix. That side is the one I would like to improve so that it more closely matches the other cheekbone, which I am very satisfied with. What I am hoping to achieve is: • Removal of the current Medpor implant on the problematic side • Replacement with a custom 3D-designed implant that is mirrored from the “good” side so that both cheekbones match as closely as possible.

A:Thank you for your inquiry on secondary cheek implants surgery. When you have asymmetry and bilateral facial implants, such as cheek implants, that typically occurs due to placement differences, natural bony asymmetry differences between the two sides or some combination thereof. Thus you are correct in that the ideal approach is to make a 3-D design based on the good side to be placed on the undesired side. The problem with this approach with Medpor material is that it simply is almost never seen on a 3-D CT scan and even if it is visualized only part of the implant usually appears. Only in very rare circumstances, and I have seen thousands of 3-D CT scans with the implants on them, is a Medpor implant ever really adequately seen. Thus this throws a wrench into the best way to treat your cheek implant asymmetry.

There are alternative strategies to this ideal plan to treat your cheek implants asymmetry but these or not is optimal as the 3-D mirrored approach. But before delving into what the less than ideal treatment optiokns are it is reasonable to first get a 3-D CT scan to be certain that these other less than ideal approaches may need to be considered.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Does you perform the “Vertical Restore” facelift?

A:Yes. But patient selection for this type of facelift is absolutely critical. The more vertically oriented facelift requires a superior vector in which the incision must run along the temporal hairline. This is what allows for the lift to be largely vertical rather than more posterolateral direction that is seen in more traditional forms of facelift surgery.  You can’t run this incision into the temporal hairline as in other facelift surgeries as you are  going to eliminate any preauricular tuft of hair in females which is usually very undesired. In men this can be overcome by growing out the sideburns longer but the appearance of the temporal  hairline scar may also be perceived as worse in the male patient.

The point being is every surgery has its benefits and trade-offs. One just has to be certain that the trade-offs for the benefits are worthwhile. Certainly the vertically oriented facelift is one of these surgeries where this issue has to be considered very carefully.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in shoulder widening surgery. My height is 188cm, waist measurement 72cm weight of 69kg and bideltoid measurement of 47cm. I have already tried the gym but even with 15kg of added muscle weight my shoulders look the same.

A:Thank you for your inquiry and sending your pictures. Unlike shoulder reduction, shoulder lengthening is more challenging due to the soft tissue attachments of the shoulder girdle. As a result there are limits as to how much shoulder widening can be done buy clavicle lengthening. In my experience that is usually 15 to 18 mm per side, and rarely 20 mm per side. While I always would like more, at least 25 mm per side, I have yet to see a patient in whom I can make that occur. Therefore in looking at shoulder lengthening one has to decide is the result that can be achieved worth the effort. In that regard I have attached some imaging of your shoulders and what I believe the outcome of the surgery would be.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want a more aesthetically pleasing forehead. I have a high hairline and a narrow forehead. What can I do?

A:Your goals indicate a desire for both forehead-temproal widening and hairline lowering. The problem is each one is contrarian to the other. Meaning they can not be done at the same time. When you augment the forehead-temporal area you limit how much, if any, the hairline can be lowered.  And vice versa. Thus to achieve both it needs to be a staged procedure. My recommendation  is to do the frontal hairline first which by itself will make the forehead look wider.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi! Im reaching out wondering If based off these images if I’d be a candidate for skull reshaping, i have flat head syndrome and it is my biggest insecurity. I ideally want more projection in the back of my head, especially near the upper part as it kinda slopes inwards instead of outwards and limits my hairstyle choices and causes me to feel very insecure. Thank you very much!

A: Thank you for your inquiry and sending your pictures. You have a classic flat back of the head which is effectively addressed by a custom skull implant augmentation. Flat back of the heads are the #1 aesthetic skull augmentation area. The amount of projection obtained by such skull implants are based on the natural stretch of the scalp once it is released from the bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m still struggling with the same developmental dysphoria we discussed back then, and I’ve been researching newer rib-remodeling techniques such as RibXCAR and RibBOSS. Before I make any decisions, I would really value Dr. Eppley’s perspective, given his expertise with rib contouring and fixation techniques.

A: To best understand the differences between Rib Removal and RibXcar you need to read my summary on the differences as listed below

Introduction

Waistline narrowing can be accomplished by a variety of well known soft tissue procedures. Liposuction and tummy tucks (abdominoplasty) are the two main surgical procedures  used with emphasis on wide fascial plication techniques to maximize the waistline narrowing effect. Rib modification, or structural waistline narrowing, is a more recent type of procedure that is far less known and practiced. They are, however, beginning to emerge as another option to maximize waistline reduction in the properly selected patient.

Surgical rib modification for waistline narrowing is divided into two types of procedures, removal (excision) and contouring (bending). They differences are:

RIB REMOVAL (Rib Resection)

A  surgical procedure where the lower “floating” ribs (usually 11 and 12,and occasionally 10) undergo subtotal removal (outer prominences). With some surgeons reduction of the outer edge of the latissimus dorsi muscle may also be done.

Benefits

• Maximal narrowing of the waist
• Structural removal of the lateral rib prominences and overlying muscle
• Permanent change to the lower ribcage
• Minimally patient dependent (limited garment use)

Disadvantages

• More Invasive surgery with the creation of small incisional scars
• Short tern drain use
• Risk of postoperative seroma(fluid collection0
• Risk of nerve pain or prolonged soreness

RIB Xcar (Minimally Invasive Rib Contouring)

A technique developed for reducing the flare of  the lower ribcage without removing ribs. Using a percutaneous technique ribs 10, 11 and 12 are partially cut by a pieziotome and fractured.

Benefits

• Less invasive with a quicker recovery for most patients.
• Good complement to other body controlling procedures

Disadvantages

• Dependent on strict patient compliance with postoperative garment wear for three months after surgery
• Increased risks of pneumothorax (due to blind cutting and fracturing of the bone)
• Not ideal for patients seeking maximal waist reduction as an isolated procedure.

Side-by-Side Comparison

In the end it comes to understanding that the success in Rib Xcar is highkly dependent on 3 months of corset wear. If this is not done in a consistent basis the operartion does not work.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi! Im reaching out wondering If based off these images if I’d be a candidate for skull reshaping, i have flat head syndrome and it is my biggest insecurity. I ideally want more projection in the back of my head, especially near the upper part as it kinda slopes inwards instead of outwards and limits my hairstyle choices and causes me to feel very insecure. Thank you very much!

A: Thank you for your inquiry and sending your pictures. You have a classic flat back of the head which is effectively addressed by a custom skull implant augmentation. Flat back of the heads are the #1 aesthetic skull augmentation area. The amount of projection obtained by such skull implants are based on the natural stretch of the scalp once it is released from the bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I came across several of your detailed explanations about nasal sill loss after lip lift surgery, and they were the clearest I’ve found. I have a similar complication from a 2021 lift, and I’m trying to find someone experienced in revision or at least improving the appearance.If this isn’t something you treat directly, would you happen to know any surgeons who handle these types of sill repairs or camouflage techniques? Thank you for your time.

A: The problem with the Italian lip lift is the effacement of the nostril sill. It flattens it out making a runway right up into the inside of the nose. This is glaring apparent in someone who has a visible raised natural sill…which many but not all people do. There is no camouflage technique to treat it. The only way to potentially create the appearance of a sill is to add a firm graft/implant underneath the now flat sill skin. While this is the only treatment option its effectiveness is limited by the now tight skin at the sill caused by the prior lip lift.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

.Q: Dr. Eppley, Im looking to create and install custom infra orbital implants to fix my sad/tired look that has always bothered me and made me insecure. People have often told me that i look super tired and sad ive tried every undereye skincare cream there is and spent more than 1000€ for them and finally came to the conclusion that surgery would be the best option to fix them forever.

A: Thank you for sending your pictures. You have a pronounced negative orbital vector which means the midface, and the undereye-cheek area, is skeletally underdeveloped. This is a surgical problem of which only custom infraorbital-malar implants can provide effective augmentation improvement.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I would like to ask for your professional guidance regarding several anatomical concerns that affect my self-image. In different areas of my body —the sides of my wrists, my elbows, shoulders, knees (especially when I bend them), kneecaps, hips, and ankles— I have very prominent and angular bony contours. They create sharp outlines that make me feel uncomfortable with my appearance. I have taken X-rays, and they show that these protrusions are superficial bony thickenings, not part of the essential structure of the bones. They are located on the sides and are not related to muscle or tendon attachment. I would like to know if there are safe procedures to reduce or smooth these bony surfaces without harming the surrounding tissues. I’m not looking for dramatic alterations, just a refinement that helps me feel more at ease with my body. Additionally, I am interested in the possibility of: • A thoracic width reduction. • A reduction of the mastoid bone to make it smaller and shorter, in order to achieve a slimmer and narrower neck. • Shoulder reduction, including scapular contouring or shaving. • And I would also like to know whether it is possible to safely reduce or shave the acromion. I am also seeking a full-body feminization, and I am very open to exploring any medically safe options that could help me reach that goal. I would greatly appreciate your guidance on the feasibility of these procedures, the techniques involved, and the potential risks. In addition to that, I would like to have craniofacial feminization surgery with the doctor, that is, to reshape my face and skull to make it more feminine and smaller. I know all this may seem unusual, but I am starting my transition and I am not willing to leave anything behind. Please let me know what type of photos and from what angles you need, and I will send them automatically. Thank you very much for your time.

A: While I fully understand what you are trying to accomplish, of all the body areas you have mentioned only the shoulder reduction with scapular shave is a current viable treatment option.

The face, however, is a different matter as there are many established and effective facial feminization procedures.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Do you perform anterior rib-10 / costal margin reduction? I have a lifelong prominence of the anterior costal margin (rib #10) directly under the breast fold. This sticks out even when I’m lying flat, and it’s not related to posture or abdominal tone. I am NOT interested in waist-narrowing procedures or removal/remodeling of ribs 11 and 12 from the back. I am looking exclusively for surgeons who treat Isolated anterior rib-10 / costal margin protrusion via an anterior or inframammary approach with cartilage contouring, reduction, or reshaping. Ideally combined with a breast implant revision.Thank you very much

A: I have performed many subcostal rib resections  for varying amounts of flare and protrusions all of which are cartilaginous in nature. Such rib protrusions are highly variable and could involve  any number pf subcostal ribs from 7 through 10. At the inframammary fold level that is closer to rib 6 or 7. But regardless of the rib number(s) a preoperative 3D CT scan is needed to fully understand the number of ribs involved, the exact shape of the protrusion and how best to treat it. (Shaving, resection or bending)

I can not say whether such costal rib reductions could be done through an inframamary incision (usually unlikely). But the first place to start fro an assessment is to see pictures of the protrusion both erect and laying down.

But regardless of whether a subcostal rib protrusion can be reduced through an inframamary incision or not breast implant replacements can be performed at the same time.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, what material is being used for skull implants? – is there a lifetime for the implants? Doe they need to be removed after a certain period of time? – Can the implants move/ change their position? – what is the chance of rejection of the implants? – what is the chance of alopecia? – as a EU citizen I would like to know how long I need to stay for control/ post-surgery treatment.

A: In answer to your skull implant questions:

All aesthetic onlay skull implants are made of a solid silicone material which is permanent. It can not suffer failure and need replacing like gel-filled breast implants.  While skull implants like all implants have a risk of infection (never seen one yet) there are a completely biocompatible material so there is no risk of rejection. Because of their size and surface area coverage, amongst other factors, they can not shift position or move after surgery. As long as the size of the skull implant is not excessive for the thickness of the scalp there is no risk of long term alopecia.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, You did a custom forehead implant for me on six years. I am very pleased with the results. The reason I’m contacting you today is because I’m going to have an MRI of my prostate. I just want to confirm that the implant and the screws are safe to go into a MRI machine. If you can email me the manufacturer’s implant card or manufacturer, material, model, and serial number, I would greatly appreciate it. I already contacted your office and signed a medical release form. They emailed me the operative report, but I don’t see the implant information in there. I’m having the MRI in one week so I’m trying to speed up the process by contacting you directly. Thank you very much for your excellent work! 🙂

A: Your skull implant is composed of solid silicone and the small microscrews used are of titanium composition both of which are MRI compatible. For over 30 years all forms of skull implants are made of MRI compatible materials with the awareness that any patient may one day need to have such a radiologic study.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a transgender woman 48 y/o. I’m starting the planning process for facial feminization surgery. Any help or information you could provide would be greatly appreciated. Thank you.

A: In facial reshaping surgery the first thing you need to do is generate a list of your facial shape concerns in the other of their priority to you. In other words what facial features so you see that would benefit you the most in terms of having a more feminine appearing face. Once that is known then imagine can be done to determine how those changes may potentially look.

It is either that approach to the alternative approach is let the surgeon first do it and then see how it looks to you.

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley, I previously had double jaw surgery and V-line surgery that I regretted. After that, I underwent reversal double jaw surgery and received a custom jawline implant to restore my appearance, based on my before-and-after surgery CT scans. These procedures improved my appearance and reversed the changes to a certain extent, but my face still isn’t exactly the same as it was before. Does this mean that even with CT scans and a custom jawline implant, my appearance can never be fully restored to how it used to be?

A: There is a lot of information about your case I do not know but as a general statement,it is fair to say you can never go completely back home. It doesn’t matter how close you get the bone to it’s original state there are irreversible changes to the soft tissues  from the surgeries that can never be completely overcome.,

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley, https://www.eppleyplasticsurgery.com/how-much-shoulder-widening-clavicle-lengthening-can-be-safely-achieved/ I was wondering if you’ve learned anything new about the limits of clavicle lengthening, as well as its correlation with wingspan.

A: There have been no improvements as to how much clavicle lengthening can be achieved per side (15 to 20mms). Nor do I envision that happening any time soon as the limiting factor is the soft tissue attachments of the shoulder girdle, specifically that of the scapular attachments  to the humerus through various stabilizing and rotating muscles. These are attachment issues that even distraction lengthening is unlikely to be able to overcome.

I have never yet made any measured correlation to clavicle lengthening and its effects on wingspan. At the least it should have a linear correlation with the amount of clavicle lengthening but I would suspect its visual effect is greater than its measured effect. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi there Dr 👋I’m wondering if you can help me. I am really insecure about my forehead scar from a previous hairline lowering surgery. They made it too low, so I had to have some of the hair removed to make my hairline bigger again, but now the scar is evident. Ive been told I could have a tissue expander then surgery to remove the scar.

A: You nave correctly surmised that the only way to lengthen a forehead (move back the hairline) is to expand the forehead skin to allow it to stretch. While that scar you have now would be removed there will be a new scar further back from the forehead lengthening. The tissue expander allows the hairline to move back but does not in the end eliminate a hairline scar.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am considering a lower blepharoplasty as well to reduce sclera show. Do you also offer fat grafting on the upper eye region to reduce upper eyelid exposure?

A: A lower blepharoplasty in the traditional sense is not an effective method for treating scleral show. Improving sclerai show requites a multitude of procedures which could include infraorbital rim augmentation, spacer grafts and lateral canthopexy/plasties.  It is a challenging problem to improve for which no one or simple procedure will work.

While fat grafting can be done to the upper eyelid to improve the depth of the fold it will not necessarily reduce upper eyelid exposure. It depends on what you mean by upper eyelid exposure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q:Dr. Eppley, My skull depression is about 2.5” by 2”. My only concern would be pressure on my skull/brain over time.

A: No form of external skull augmentation has any risk of putting pressure on the brain which is protected by the intervening bone layer.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in speaking with the Doctor about having pectoral implants done, both to increase size and correct a structural asymmetry. I previously had implants surgically inserted. Unknown to me at the time, the Doctor had detached the muscle (which wasn’t noticed due to the general healing from the surgery with the drains to remove any bleeding and edema from that trauma, as well). Secondarily I had the sternal head of the left pectoral muscle repaired using an allograft. Since that time, however, it feels like the muscle has either detached from the sternum itself or some other structural changes have occurred as I can now feel the bone and part of the ribs on the left side. Given that I have started avidly bodybuilding since, I am ultimately looking for new implants that will both correct the appearance and possibly go with something slightly larger than my current physique would typically warrant. I plan on continue adding muscle and would rather go with an XL size that won’t end up looking disproportionate yet again in another 2 to 3 years. 

After conducting extensive research about options within the field, I feel like Dr. Eppley and his approach to custom implants designed based on 3D CT scans would be the most promising solution for my situation long term

A: In answer to your pectoral implant questions:

1) With indwelling pectoral implants and the desire for a larger augmentation, the use of 3D CT implant design is the superior method to do so. You can clearly see your pectoral implants on a 3D CT scan and that allows the ability to make a precise larger implant design with that information.

2) By your description you may be referring to disinsertion of some of the pectoral muscle attachments along their sternal origins. This is most likely to occur at the lower edge of these attachments…which is actually commonly done in breast implant augmentation but not with pectoral implants. Once that muscle area is detached there is no way to reattach it. Attempts can be made to camouflage it (fil in the contour deformity) and that sounds like what was attempted with the allograft. Larger pectoral implants will not correct that soft tissue contour issue and may even make it more apparent. This is also what can occur with pectoral muscle enlargement which may be why it is more apparent now than previously. Secondary management can be done with pectoral implant replacements and the only question there is what soft tissue augmentation would work the best.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking for a lateral commisuroplasty to widen my mouth. After upper and lower direct lip lifts the scars fused at the corners of my mouth making the opening extremely small. It is challenging to eat, smile, talk, etc. I would really like to correct this and have a nice wide smile again that allows me to take a big bite when needed!

A: Mouth corner scar contracture is a very different problem than traditional mouth widening in both goals and in the surgical technique to treat it. Scar contracture represents a tissue deficiency problem that will only get worse if a V-Y advancement mouth widening technique is used. Rather the mouth corners need to be released and opened and new tissue added through an internal rotational flap of mucosa.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am seeking a conservative chin implant overlay to add approximately 6–7 mm of horizontal projection plus 3–4 mm of vertical lengthening on top of a previous sliding genioplasty (8–9 mm bony advancement at the time, now settled to ≈5.5–6 mm). I recently consulted with a local doctor in my area that appears to have some relevant experience with chin augmentations on top of a prior sliding genioplasty. After reviewing my photos, it was recommended that a combined chin implant + deep-neck contouring/platysma tightening procedure because he believes a standalone implant on a post-genioplasty patient would not deliver an optimal or predictable long-term jawline definition. While I respect this opinion and conservative philosophy, I am specifically looking for the least invasive option that still achieves strong forward projection and a crisp submental angle. Given that I am very lean, have no visible platysmal bands, and no significant submental fat, and excellent skin elasticity, I believe a properly selected extended anatomical / pre-jowl implant as a standalone procedure should be sufficient. 

Would you be willing to perform a standalone chin implant overlay in my case, and do you believe the result can be excellent without deep-neck work?Thank you in advance for your time and expertise.

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

1) Your original chin deficiency was in the range of 20 to 25mm so a 9mm bone advancement, while helpful, is way short of the mark. So it is no surprise now that a secondary chin augmentation is being considered.

2) The debate is not between a secondary chin augmentation vs a deep plane facelift (quite frankly a bit of a silly recommendation given the actual goal) but between the method of chin augmentation (implant overlay vs secondary bony genioplasty).

3) Once a bony genioplasty is performed the soft tissue chin pad is going to be tight. You will be lucky to be able to place an implant of 3 to 4mms of added horizontal projection and any vertical lengthening (Iwhich you don’t need) is not going to happen as the chin pad will not follow it down.

4) When more then 3 to 4mms of added horizontal augmentation is needed you have to move the bone.

5) Therefore what you really need to decide is whether you want an implant for just a very minor improvememnt or a more visible change by moving the bone.

Dr. Barry Eppley

World-Renowned Plastic Surgeon 

Q: Dr. Eppley, Given that I am planning to undergo a comprehensive facial rejuvenation, including a midface lift and a neck lift, how should the suggestion for custom infraorbital-malar implants be evaluated?

Specifically, will the soft-tissue repositioning achieved by the midface lift be sufficient to address my volume concerns in the infraorbital and malar areas, potentially making a custom implant unnecessary, or are the implant and the lift considered complementary procedures to address different components (skeletal vs. soft tissue)?

A: The simple answer is….you can’t lift away a volume deficiency issue…and often such attempts make the volume deficiency worse. The reverse, however, is more true. By adding volume (custom infraorbital-malar implants)  the need for a lift is reduced or at the very least greatly reduced.

Dr. Barry Eppley

World-Renowned Plastic Surgeon