Your Questions

Q: Dr. Eppley, Also my hair is not covering the scar where the forehead was inserted. It’s 2.5 month now since the surgery. Is this expected? Shall I wait longer or do I start considering hair transplant? I think I can see some hair growing but I don’t understand why the gap. I can temporarily hide it with Toppik. What are the other patients’ experiences on this?

A: While some shock hair loss is not common around scalp incisions it can occur. Some to complete regrowth is to be expected. Treatment should include topical minoxidil until 6 months after surgery. Hair transplants would not be considered until maximal regrowth is seen.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a medpor chin implant done about 15 years ago and have felt it’s too masculine (wide) and would love to have it altered (not removed) – customized to fit my face better. I’ve seen several local plastic surgeons but none have experience with Medpor implants let alone modifying one.

A: It is not effective to attempt Medpor implant revisions with the implant in place…that will not work. You have to remove it. And in removing it it will only come out in pieces. So you might as well get a new implant that is better aesthetically suited for your needs.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am the not-so-proud owner of some XXY testicles and one very large empty sac. I swear, I am the typical 70s Ken doll with a nub. While the testicles work modestly, I’ll never want to parade around in a speedo. I’m wondering if you have done the envelope testicles for an XXY patient.

A: The wrap around or envelope testicle implant have their issues with the risk of eventual separation. Thus I prefer the side by side technique which overwhelms the naturally small testicles and never has a separation issue. The key is a large enough custom testicle implant, usually 6.0cm or greater.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I also need the dr opinion on this if he can answer me back : So I want to achieve smaller and more masculine eyes to get to more hunter eyes look. A surgeon in the US proposed lower lid retraction with alloderm graft with canthopexy but I have been reading a lot about the procedure and seems its better to have supra and infra implants with a skull specialist like your self to achieve more natural hunter eyes look and without the need canthoplasty. What do you think kind sir ?

A: Hunter eyes are hard to achieve and it often takes a combined hard and soft tissue approach. If one has good periorbital bony projection then soft tissue procedures alone would be adequate. (alloderm graft with canthopexy) But of the brow bones and infraorbnital rims are less projection or flat then periorbital bone augmentation would be needed as well. Each patient’s needs must be determined individually.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am having paying following a revision chin implant surgery I had 5 months ago. I have a small silicone implant with wings. I believe the chin implant is slightly skewed to the right after rolling over onto my side in my sleep a week after surgery. The implant is visually just slightly crooked, almost not noticeable. I would say aesthetically, it looks alright, just slightly crooked and good projection from the side.

However, I am having an increasing amount of nerve pain at the lower right side of my chin, where the “point” of the implant is skewed to. I have a small implant, though I am not sure what mm it is. This pain has been sharp and increasing in the amount of times I feel it as time goes on. It started about a month or so after surgery, when swelling started to go down.

Before this, I had a small silicone implant with no wings placed 6.5 years ago, and it became dislodged to high after a fall a few weeks after surgery. The implant was uncomfortable and noticeable too high, which I eventually wanted to get replaced. Though, now my replacement is causing a new kind of uncomfortable pain.

I would like to either have the chin implant revised again, or completely be removed and be done with this once and for all. I am worried about chin ptosis upon removal, so I wanted to talk through my options with an experienced surgeon like yourself. I have provided photos of my revised chin causing nerve pain with a little drawing showing where the nerve pain is happening.

A: Your nerve pain indicates, with an extended anatomic chin implant, that its wing is impinging on the mental nerve. This can be proven by a 3D CT scan. The longer you leave the nerve impinged the less likely it will recover once the compression is removed.

The logical approach is to take the chin implant you have, remove its wings, and center it with screw fixation.

Chin implants don’t move or migrate when they screwed down.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to get your thoughts on the process of perhaps moving the alar and columella base on the nose up about 2 mms or so. I’m not sure how close the actual nasal cavity is above the base of the nose, but with a lip lift to hopefully forgive some of the scarring from moving the nose upwards, is this theoretically possible?

The image I’ve attached is the normal nose length on the left, on the right is my nose edited a bit shorter.

Thank you for your time.

A: Nostril/columellar lowering works because it is done by skin removal giving the nasal base a place to go. Conversely nostril/columellar elevation would require filling in the space created by the elevation with a skin graft. Besides leaving a prominent scar from the graft the relapse/contracture rate from skin grafting is high and thus the procedure would be ineffective. In essence going down can work but going up won’t.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m a 30 year old trans woman that underwent facial feminization surgery earlier this year. The surgery was a success, and I look beautiful and certainly got what I asked for. However, I’ve since realized that I wasn’t quite specific in my instructions with my surgeon about the level of reduction I was seeking in my orbits vs the sinus bone/center of the forehead. While I wanted a flat/round center of the forehead, I’ve now come to recognize that I would still like some slight orbit definition (but certainly reduced from where I once was). However, in surgery they were totally smoothed out.

Is there a way to restore some minor definition to the orbital bones with a custom implant or bone paste?

A: It is not rare to see a brow bone reduction patient vis bone flap setback technique to end up being flatter than they desire. A custom brow bone implant design can be made to do any amount of partial brow bone restoration.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I only have one question I would like to know the answer to. 5 years ago I had a Su-Por cheek implant made of pure high-density polyethylene (HDPE).

I would like to undergo the Zaffiro laser treatment. This is facial thermolifting. The skin heats up to a maximum of 70 degrees Celsius.

Can this damage the implant? Unfortunately, neither a cosmetologist nor a doctor is able to answer this question.

A: This is basic material science. This can be determined by knowing the melting temperature of porous polyethylene. For high-density polyethylene the melting point is typically in the range 120 to 130 °C (248 to 266 °F). The melting point for lower density polyethylene is lower, typically in the 105 to 115 °C (221 to 239 °F) range. Medial grade facial implants are made of high-density polyethylene.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a pretty severe asymmetric lower jaw. Much more bone on one side than the other. I’m wondering if I am a candidate for an implant that would improve appearance.

A: You would be assuming that the bigger side of the jaw is the preferred side. A 3D CT scan will provide the definitive view of how different the two sides are as well as the platform for building an implant for asymmetry improvement.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi I have tightness 5months after sliding genioplasty (8mm) and chin implant removal (10mm) my surgeon is suggesting steroid injections. Is this safe? Does Dr eppley do this and is it good idea to try?

A: The issue with steroid injections is not about safety but effectiveness….particularly 5 months after the surgery.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve noticed asymmetry in my eyes. My left eye and eyebrow sits lower than my right eye. I’ve only noticed this recently because I don’t take a lot pictures ansmd when I do I only take selfies with my head tilted. I’m interested in surgery to correct this and was wondering if I’m candidate for this procedure. I’m interested in visiting your office eventually for a ct scan but since I will be coming out of state, I would like to know more about it before I make the trip. I’m 26 years old by the way. I’ve looked at the before and afters on your website and I hope my results will be like that as well. I was also wondering the long term effects of the implant and the frequency of revisions after this procedure. Thank you and I look forward hearing from you

A: The definitive test for potential vertical orbital dystopia (VOD) surgery is a 3D CT scan. How low is the entire orbital box on the affected side. (needs to be 5mm or less to be successful in my experience with non-orbital box procedures) Yours is close to that limit. (see attached)

The 3D orbital CT scan is one where you get where you live and we place the order for it to be done. Then you send the scan to me. You do not need to come here for the scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi there, I’m a 30yo male and am curious about a brow bone reduction. I am bald so I have been hesitant as I thought the scalp scar would be too visible after the procedure. I’m curious if this is not a concern or if there are other options available? Thank you

A: In the bald male one does have to be very thoughtful about the scar tradeoff and a scalp incision would never be used for brow bone reduction. The incision would be much smaller and lower either in a central horizontal wrinkle or even at the top of the eyebrows. (one on each side)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have 2 bony bumps on the forehead from birth one and bigger than the other in fact it is the upper part of the skull which is asymmetrical 

and I would like to know exactly if it is possible to remove them or file them and if it is possible to have a completely smooth forehead or just reduce them as well as a reduction in the forehead line.

A: You have classic but very prominent asymmetric forehead horns. It would take a 3D CT scan to look at their thicknesses to accurately answer the question of the completeness of their removal. But based on my experience I would suspect they can be reduced but probably not 100%

The other option is to go in the opposite direction with some reduction (or no reduction) and then augment the forehead around and over them to make everything smooth. This would be the absolutely assured method of a completely smooth forehead.

But I would not guess and first get the scan.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am an 18 year old boy and i have some questions. My mother told me that when i was born my head was not fully formed yet and that she used to put pillows around my head when I sleep so that it could form. I today see pretty clearly that my side profile from the left and from the right don’t look the same. My right side of the backhead looks normal but the left side looks strange and very “flat” in one place. This makes me very insecure and I want to know if its all in my head, if its due to my hair growing a certain way as its pretty wavy/curly or if there really is a problem?

 A: I would obviously need to see some head pictures but I suspect you are referring to having plagiocephaly with one side of the back of the flat compared to the other.

By your description the problem is certainly in your head but I think it lies on the outside of the skull rather than internally…meaning its real.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I was diagnosed and treated for Hodgkin’s Lymphoma twenty years ago. As a result of the chemotherapy I have hypogonadism. Is the wrap around implant an option i could consider?

A: In cases of very small testicles the superior testicular enhancement procedure is the side by side displacement technique which can easily overwhelm/hide the small testicles. Wrap around testicle implants have a high risk of disengagement when there is little to hang onto.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a question regarding the submental chin reduction procedure for a horizontally protruded chin. Specifically, I would like to understand whether the process of bone burying might lead to scarring that could result in tissue stiffness or skin dimpling. Would these changes be noticeable when the patient’s face is at rest, during conversation, or while smiling?

Thank you for your insights on this matter

A: Chin pad stiffness is not a postoperative issue that patients have ever mentioned to me. The most likely postop ‘problem’ is the potential for some chin pad dimpling when smiling…but this potential effect is usually mitigated with the removal of some of the soft tissue chin pad through the submental approach. (excision and tightening)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a sliding genioplasty done last year, I had some concerns when I smiled, that my chin felt like it was pulling down and thus, from a side angle, made my chin look extremely bulbous and pulled down looking. So, my surgeon suggested there may be some issue with the internal hardware and impacting healing. This year I had the internal hardware removed and my muscle stitched back up into place. Now when I smile, I do notice it is much better, however the bulbous chin appearance is still there. I’m interested in learning more about perhaps removing the soft tissue in my chin and shaving/burring down the chin bone about 3 – 4mm. The original advancement was 8mm. Please let me know thoughts or if there is an opportunity at all to correct the soft tissue concern and slight over projection (that I feel). Thank you so much in advance!

A: While a submental approach can be used to reduce the bony projection and remove/tighten the soft tissue chin pad, this will create a scar under the chin whose tradeoff must be considered very carefully in females…particularly those with intermediate skin pigments.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Just out of curiosity… I know that sometimes people will just have larger ones placed in front of the smaller testicles and I’m wondering how much that cost to do, or if that’s even an option with Dr. Eppley.

Also, is there an option where you can do the ones that wrap around the testicle but aren’t custom ordered? In other words are there pre-made versions of that particular style?

A:You are referring to the side by side or displacement testicle implant

technique.

There are no non-custom wrap around testicle implants.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hey there, I just have a question about the orbital rim implants, is there a screw involved in the procedure?

A: Yes, a titanium microscrew.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, How much does skull reshape surgery cost?

I want to make my flat crown area rounder.

Age 32,

Weight 165 pounds

Height 5’11

What is post surgery process and how fast can person recover and return back to work afterwards?

Does the hair grow back up?

A: As I understand your skull reshaping it is a crown of the skull augmentation which is down using a custom skull implant designed using the patient’s 3D CT scan. Recovery from such a skull implantation procedure is often quicker than one would think. Most of the recovery is about swelling and how mucgh time it takes to go away.  (10 to 14 days) In regards to returning to work the critical question is what type of work are you returning to?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Bonjour j’ai un crâne allonger depuis ma naissance. , j’ai 31 ans et j’aimerai savoir si ce handicap pouvais être soigner

A: You undoubtably have some form of congentall sagittal craniosynostosis to have siuch a long anteroposterior skull length. The question is whether the occiput (back of the head) could be reduced enough to make the surgical effort worth it. It would require a CT scan to determine the bone thickness to see how much reduction could be safely achieved.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, . After giving it more thought, I believe that the reason I dislike my shoulders is not because of the size but because of the shape of the clavicle joints. So a shoulder reduction would not address that.

I was wondering if Dr Eppley could take a look at the photos I’ve attached below and let me know if there is anything that could be done to reduce the clavicle joints (for example with shaving down). I know he has blog post in which he describes a surgery where scapular shaves were performed, so it would be more similar to that. 

I am very interested in Dr Eppley’s response

A: What your concerns are is the amount of bone show that the distal clavicle and AC joint show. (see attached diagram and x-ray) While some of your distal clavicle and joint show could be reduced I don’t think enough of a reduction could be achieved that the result would justify the effort and scar. You can’t overly weaken the clavicle bone nor enter the joint space.

That being said as a general statement of AC joint clavicle show, your distal clavicle show is unique. While you have a lot overall clavicle show the distal clavicle actually bows upward and then goes back down into the AC joint. This distal bowing provides room for a safer clavicle bone reduction that would avoid entering the joint space. (see attached picture) Your side view picture shows it best of how prominent the distal clavicle is which does not even allow for the acromion process of the AC joint to show as it would in most people.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have to say I am very interested in the locking mechanism of your own design from a recent blog post. I can’t help but wonder if this could be utilized to facilitate slightly larger implants? As you have noted previously, due to the vertical placement of hip implants they are at risk for impact forces over time, folding, mal-rotation among others. Of course to mitigate some of that you can use higher durometer implants with the trade off being less of a feathered edge and likely more risk of implant show especially in thin patients. Perhaps if you created a locking mechanism for larger implants (see see pictures for my potential interpretation based off of your previous designs), you could use the iliac implant as a boney anchor that would support the implant, with less force directed to the inferior edge as a result. This might allow you to use a softer durometer implant with a more general and natural appearing feathered edge.

A: In comments to your inquiry:

1) Higher durometer implants can have very feathered edges. Implent edging is not affected by material durometer.

2) A major component of Implant show is a thin subcutaneous fat layer.

3)  The locking mechanism for hip implants used with iliac crest plates can be used with any implant design or size.  Its major benefit is that it would prevent implant bending at the bottom edge of the implant.

4) One developing idea for hip implants is to use a very small iliac crest plate fora superior bone anchor for hip implants.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ll have braces to widen my smile arch and veneers to restore my teeth to it’s original condition. I also want my downturned mouth corners to be more straight, and lips a tad fuller, with an even oral fissure.

I know that braces can widen the mouth a little bit and make the lips a tad thicker due to the muscle stretching thanks to the wider dental arch (a nice effect for me), and must be done first.

My main concern is that I can’t find anything about what to do first after braces, if veneers before touching the lips, or the work on the lips first. All the information I’ve found is contradictory, with the surgeons saying “deal with the teeth first” and the dentists saying that they “follow the lip line” (which will be different after something like a corner lip lift or fat grafting) to design the smile. To add even more confusion, some cosmetic dentists say that veneers can make the lips a bit thicker if desired.

What should I get done first after braces: the veneers or the lips? I’ve attached you a picture of my lips next to someone who was similar lips to what I want to achieve, for reference.

A: Like building a house do the framework first and then worry about the exterior. Finish all dental work needed/desired and then see what the lips look like and go from there.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have a question. Can u do “hunter eyes” ?

A: Yes,. Hunter eyes is defined as an elevated lower lis and corner with a more narrow eye aperture. In some men that may also mean a lower brow bone and decreased upper eyelid space.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I’m wondering if plagiocephaly can be improved with skull reduction? I suffer from plagiocephaly, so my head is extremely crooked and the left side of my head sticks out a lot. I’ve been insulted and mocked on my head shape many times due to this. Skull implants are not an option for me as my skull is already huge and so a skull implant will only make it bigger, and it also won’t help the fact that my head sticks out so much on one side. So I’m really hoping a skull reduction will help. My head shape has ruined my life so I’m willing to undertake even the most risky of procedures in order to look normal. So I’m wondering if a skull reduction could indeed improve the look of my plagiocephaly?

A: How much the enlarged side of the head could be reduced depends on the thickness of the protruding bone. Only a CT scan can make the determination of the amount of bone reduction that is possible.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What is the intraoral approach for reduction of the soft tissue chin pad effective?

A:The management of the excessive soft tissue chin pad with any form of chin reduction has always been an important  consideration…which is not really a new concept. But I think for those surgeons who are focused only on an intraoral approach that is always going to pose a problem. But when the submental approach to horizontal bony chin reduction is done the excessive chin pad is removed as part of the procedure. I have done that approach for decades so I would not call it a new or revolutionary approach. It has always been the anatomically correct approach to many chin reduction patients

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, For webbed neck surgery:

1) what are the risks? – could there be muscle or nerve damage involved?

2) are the imaged photos below the best possible outcome or is there a chance I could see more significant results

A: In answer to your webbed neck surgery questions:

1) Muscle or nerve damage has never yet occurred in webbed neck surgery. So that risk is very low.

2) The purpose of the planning pictures is not to show patients the exact result they will get…as no one can accurately predict any surgical outcome. Rather the imaging is done to show patients what may be the LEAST amount of outcome that I think will happen. In other words if this is the best long-term outcome would the patient still choose to have the surgery? The trigger for surgery should not be hoping for the best outcome. Rather it should be what is the least outcome I can expect. Might the result end up better than the imaging….maybe. But what if it ends up just like the imaging…would you still undergo the surgery?

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, What is the largest testicle that a patient can receive?can receive?  I currently pump and feels my scrotum is pretty stretched

A :Its more about what size that the scrotum can accommodate. The largest size testicle implant I have made and placed is 8.5cms. But there are numerous factors that influence testicle implant size from height and weight to how flaccid is the scrotal sac.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m looking for a correction for my impression of eyes spread that I’m not sure I have hypertelorism. I measured my interpupillary distance is 64mm, I don’t know, where it places me, I would like to have your advice on the question in terms of solutions to my problem.

A: The proper surgical solution is transcranial orbital box osteotomies …which is not a procedure I recommend for an adult.

Dr. Barry Eppley

World-Renowned Plastic Surgeon