Your Questions

Q: Dr. Eppley, Interested in a consultation for JAW IMPLANT. I already have a chin implant from a previous 2016 surgery.

A:Many custom jawline implant patients have a prior history of a chin implant. The question is not whether the conversion to a full jaw augmentation can be done but what type of lower facial change are you seeking. To begin that visual discussion of your jaw augmentation goals I would need three pictures to do that initial imaging. (non-smiling front, side and ¾ views)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would be open to discussing the wrap around jawline implant further. Is it possible to see the impact of this on the front profile?

A:You are probably not properly interpreting what the role of facial imaging is. It is NOT done to show what you are going to looking like as no one can predict that with certainty. Rather it is done for two purposes: 1) to help the patient make a choice between different procedures if such options exist (which in your case they do….jaw angle augmentation alone vs total jaw augmentation) and 2) based on that choice what flavor of change do they want of their chosen procedure. For jawline augmentation the side and oblique views provide the best way to determine #1.

In other words imaging is done to help the patient make procedure choices and then use the imaging to determine what their goals are from which the surgery is designed to try and accomplish…which may or may not hit those imaged targets exactly.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,I have cheek asymmetry after a cheekbone reduction fracture repair and I assume it is due to how the fracture was repaired.

A:I have reviewed your 3D CT scan which shows the cheek asymmetry between the two sides. (see attached) While the left ZMC fracture repair was decent it is underrotated a bit back out (not uncommon) hence the bony asymmetry. The inferior plate can be seen to be detached from the maxillary bone which is probably why it didn’t hold up as this is the buttress to get optimal rotation. That issue aside the bony asymmetry is most ideally addressed by a custom overlay implant to optimize the projection of the left cheek bone to the other side.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, How can I reduce this ridge in the top of my head? Do I need sagittal crest reduction. I have attached my skull CT scan for you to review.

A:I have reviewed your CT scan which has been enormously in determining both the origin of your sagittal crest, its thickness and surgical possibilities for its reduction/improvement. In looking at your head shape and the scan your proper diagnosis is a PSEUDO SAGITTAL CREST which means it llooks like a sagittal crest but it not a true sagittal crest. This means it appears because the skull around it is lower/deficient which makes it just look like there is a sagittal crest but there really isn’t. This is evident by the following:

1) A true sagittal crest is when the bone is thicker than the surrounding skull bone. not thinner. Your scan shows that the crest is thinner than the surrounding, which beyond making the proper diagnosis also indicates a full reduction of it is not possible/safe. (see attached imaging) This does nort mean some reduction is not possible just that a complete reduction can not be done.

2) Technically it is the surrounding skull (parasagittal-parietal skull) that is deficient or too low and building up the bone around the crest creates the better head shape result and fully eliminates the crest appearance. (see attached imaging)

3) In short what we have learned from the scan is that the sagittal crest can be directly reduced but its appearance can not be fully eliminated. Full elimination is possible with an overall better head shape but requires a different procedure. (custom skull implant) The choice comes down to how much improvement does one want and with what amount of effort does one want to put into it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I discovered Dr Eppley after I was diagnosed with midface hypoplasia due to receiving cranial radiotherapy by mistake when I had Leukaemia aged 5. I did have a malocclusion Class III but that was corrected with upper jaw surgery. Under our health system in the UK the plan was to treat the remainder of my midface hypoplasia with implants, as well as a mid facelift, but the care I have received here has been very poor in achieving that so I am not looking elsewhere. I should also add I am not entirely sure how honest the government health system has been about the degree of my facial deformity so even to know that in Dr Eppley’s professional opinion would be most valuable.

A: Thank you for sending your pictures and 3D CT scan. Having had a LeFort I osteotomy you have maximized the forward lower midface advancement with conventional osteotomies. By your external appearance you would certainly be a good candidate for a custom midface mask implant. The only cautionary caveat is the prior history of radiation which increases the risk of complications with an implant. Whether that risk is minimal or of some significance is not known and having had radiation decade ago does not lower that risk. The adverse effects of radiation do not change with time.

With an implant in a field of prior radiation there are two approaches. One approach is to just place the implant and see what happens. This would be a reasonable approach if the risk of complications was known to be minimal. The other approach is to pretreat the midface tissues with fat injections to improve the vascular quality of the soft tissues. This would be the approach of the risk of complications was known to be moderate or even high.

The dilemma is, of course, that no one knows what your risks are from prior radiation. And there is no test to make that determination. The only preoperative ‘suggestion’ is that youm healed satisfactorily from a LeFort osteotomy…although this is an autologoous proceduer and not an implant-based one.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  I’m experiencing complications following DJS and genioplasty – specifically extreme tightness in my chin at rest (gets worse when smiling or talking) my lower lip is curled in and the outside corners are being pulled down, new lip incompetence (did not have prior to surgery) I’m exploring genioplasty revision options but I’m concerned that reversing the forward movement of the chin might contribute to more lip incompetence since there was CCW movement in the maxilla. I’ve included my before and after planning images. The maxilla was advanced 3mm forward and CCW rotation, the lower jaw BSSO forward movement was 7mm, and the genioplasty was another 6mm. I am very petite and I’m concerned that these movements were too aggressive. I can hardly sleep with the tightness constantly pulling on my chin and the mouth breathing issue is also constantly disrupting my sleep.

A: The bony movements alone do not explain your symptoms. The amount of forward chin movement (6mms) is not excessive even when combined with a mandibular advancement….at least by the numbers. How it looks aesthetically I can not say as you have provided no before and afters to evaluate.

This sounds more like intraoral chin scar contracture of which its treatment would be either a subtotal genioplasty reversal, an intraoral scar release and dermal-fat graft or a combination.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I am interested in speaking to someone regarding front bossing procedure and forehead lowering.

A: Thank you for your inquiry and sending your pictures. The combination of a high (long) forehead and frontal bossing are aesthetically synergestic….and not in a beneficial way. A long forehead can make the bone appear more protruding while frontal bossing makes the forehead look longer.

While optimal results in forehead reshaping comes from a combination frontal hairline advancement and bony forehead reduction, they usually do not provide an equal amount of contribution to an improved shape. In many cases, and yours is a good example, the hairline advancement provides the most benefit.

Thus gettng a maximal hairline advancement is critical and, while I would want to see where you want your frontal hairline to be, it is likely it is a least 2 cms forward. But before making that presumption I need to see your frontal hairline goals by drawing on your forehead your desred new hairline location. This is critical information as it can affect how the hairline advancement is done.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello. I am a transgender woman from England. i previously have had two jaw surgery and also mandible shaving as part of a few facial feminization procedures however they removed too much bone so i have a very weak mandible angle. would you be able to tell me if you do custom jaw implants? and how much roughly do they cost?

My issue is i have previously had jaw shaving v line but they removed too much bone so now i have very asymmetric weak mandible.

A: I have done many custom jaw angle and jawline implants for subtotal or total V line surgery reversals. Over resection in Non-Asian patients is not uncommon as the size and shape of the Caucasian lower jaw is often different.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello! I want to have rib removal for a smaller waist & I’ve previously enquired about shoulder narrowing surgery. I am set on having 2.5cm removed on each side. As for rib removal, I have a couple of questions. Would it be possible to remove both the 11th & 12th ribs during the same surgery? If so, would it also be possible to have the rib removal & shoulder reduction both during the same surgery? How much would it cost in total? Thank you so much & have a great day.

A: It is common to perform bilateral 11 and 12 rib removals at one time as well as combine that procedure with clavicle reduction osteotomies. Almost always 2.5cms of clavicle bone is removed per side.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I would like to inquire about a consultation for chin ptosis treatment. It’s congenital, I’ve had it all my life and never had any facial surgery. I tried Botox for the first time a couple weeks ago for it and I feel like it made it even worse.

A: I am not confident that congenital chin ptosis in its entirely can be improved…at least the lower lip position can probably not be improved. The overhanging chin pad and the deep siubmental crease can be improved by excision.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, 1. Would any cosmetic skin treatments like microneedling or Fraxel laser therapy pose a risk to my implants? (in particular the malar implants but also the chin or jaw implants)

2. Have you ever heard of apthous ulcers causing jaw hardware infection? I am taking rapamycin for longevity benefit, and this drug causes occasional canker sores. I want to make sure that I don’t put my jaw hardware at risk, and would stop the rapamycin if you thought there was a significant risk that a canker sore could lead to a hardware infection.

A: In answer to your questions:

1) Facial implants are not at risk from any ‘invasive’ skin treatments such as microneedling or laser resurfacing.

2) Apthous ulcers are a superficial mucosal (wet or dry) eruption that is far removed from the subperiosteal location of your facial implants. There is no infectivity risks to your implants from them.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is it safe for someone to get Botox if they are allergic to cow’s milk, Casein & or egg?

A: Botox is a synthetically derived toxin in which its production does involve albumin, a cow’s mild protein. So if one has a true albumin allergy then one should not get Botox. However  a lactose intolerance does not count as an albumin allergy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, you did my breast augmentation back in February of 2017. I have had a wonderful experience so far! I am simply curious when or what I need to do to “check” to make sure they are good. I know it’s usually 10 years it is requested to get new ones, but can go longer. Just seeing if I should be planning for something in the coming years.

A: Good to hear from you after all these years. With silicone breast implants there is no reason to ever replace them unless they fail. (disruption of the containment shell known historically as a ‘rupture’) Unless you have implant symptoms (pain, change in breast shape) you just get your mammograms as you normally would do on that schedule which will also show implant integrity There is no need to replace them every ten years unless there is a compelling reason to do so as per above.

Short of any symptoms of implant failure you may live with them for many decades or even the rest of your life.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to ask you if there would be a change in volume compared to the extension, that is to say will there be more volume once the implant is placed?  Or will the change not be very different compared to the scalp extension volume? 

A: While a scalp expander and the skull implant may have similar volumes they have radically different shapes. Scalp expanders are round while the skull implant has a more oblong skull shape as you have seen in the design file. So don’t confuse the external effects of these two.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I hope you’re doing well. I have a lip deformity that developed after I underwent double jaw surgery and genioplasty almost a year and a half ago.

At rest, my lips don’t meet naturally and I need to force my lips closed since my bottom lip drags down and rolls outwards which exposes the wet mucosa. Forcing my lips closed causes me pain in my lower lip and chin area.

I’m thinking if I somehow can permanently augment my upper lip it will close the gap I need to force shut therefore reducing my pain. I’m interested to see what the doctor would recommend.

A: i think you have had too many alterations in the perioral region (subnasal lip lift, double jaw surgery, genioplasty) that the structure and elasticity of the lips has been adversely and probably permanently affected. The key for your lip incompetence is not to try and make the upper lip go down to meet the lower lip….as that will never happen and the upper lip already covers all of your upper teeth. The correct diagnosis for your lip incompetence is that the lower lip is pulled down as the excessive lower tooth show demonstrates. Therefore the correct approach, challenging as it is, is to free up the lower lip and try and raise up it higher up. In my experience the only effective approach is vestibular/scar tissue release, dermal-fat graft and a shortening vestibuloplasty.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My son is 6 years old has brachycephaly. At what age can this procedure be done?

A: 16 years of age is the minimum age with parental consent.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in midface and cheekbone implant but am not sure if I can afford it. I was wondering the range of cost of the procedure?

A: There are two strategies to midface augmentation in the Asian patient, standard cheek (modified for anterior cheek/infraorbital augmentation) and paranasal-premaxillary implants and a custom midface mask implant. The former is what is done when the patient’s budget prohibits the latter.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to ask if you are able to conduct buccal fat rejuvenation surgery.In a previous facial surgery,I had removed about 50% of my buccal fat and I would like to see if it’s possible to restore some of this fat in my cheeks. If there is any information you can provide it is much appreciated, thank you.

A: There are two autologous methods for buccal fat restoration or reversal, external fat injections and intraoral replacement with a solid fat graft. There are advantages and disadvantages with either approach. Fat injections are a scarless harvest and placement but their survival is not completely predictable. The solid fat graft method requires a donor site but the volume of the graft is more stable/predictable.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have lip tightness after genioplasty. Can it be corrected?

A: Most lower lip tightness issues after an intraoral genioplasty represent contracture/tissue deficiency. This is best treated by an intraoral release with a dermal-fat graft. (tissue addition)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want to get a large scale partietal skull reduction done. One of your patients on Instagram had great results. Can you please give me an estimated reduction possible in cm and also estimated price. To see if it’s realistic to continue the procedure. I will add the photos of your patient in the appendix.

A: Such skull reductions are done in mms of bone thickness removed (not cms) over the reduced skull area. How much bone can be reduced is determined by a preop 2D CT scan to measure its thickness.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am a female with alopecia who keeps my head shaved. I do wear hats and wigs sometimes but also like to be comfortable. I have not found any other information on hiding the scars from facelift and necklift surgery except on your examples of bald men. Have you ever operated on a woman with alopecia? Were you able to camouflage the scarring! Any information would be greatly appreciated.

A:The key to limit visible scarring in any patient with little to no hair coverage, regardless of their gender, is to not have the incision lines extend away from the folds/creases of the ear. That is the best way to not create a scar problem. With more limited incisions comes more modest face/neck lifting results. Whether that tradeoff is a reasonable one depends on the patient’s face/neck issues and their expectations. That would have to be carefully assessed before surgery.

Dr. Barry Eppley
World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a Custom Skull Implant to help with the top ridge on the side profile and make the back of the head more rounded like a typical skull shape.

A:While a custom skull implant can very effectively add volume to the flat back of the head, it is not clear how it would help the top ridge unless the implant design crossed over onto the top as well.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I  plan on gaining weight as I’m not very comfortable with my current weight, I think I’m too skinny. So if i gain weight for the hip implant surgery id maintain that weight and then some probably, i don’t plan on staying this weight or getting any skinnier. Do you think hip implants are good idea of I gain weight?

A:I think even with any weight gain it will never be enough to significantly reduce your risk of hip implant complications.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I have got this skull deformity on the top of my head where it sort of just peaks upwards and looks like a lump. Wondering if it would be possible for you to do a reduction and cut it down to make my head shorter and then carve it so that it is a bit more rounded off instead of sharp and pointy? Or would I still need to have a custom implant to achieve this?

A:You have an uncommon top of the head skull deformity because it is both raised and flat. Usually raised midline top of the head shapes are peaked with a sharper angle. (not flat) The question as to whether an overall reduction in its height and shape can be done depends on the thickness of the bone which requires a CT scan to its thickness and how much of it can be safely reduced. A custom implant would only be used as a second option (and only option) if the bone is not thick enough to do a good reduction. It would very effectively create a more assured shape but it would make the head a bit taller.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I found your information from an online article I came across last night. I am reaching out to request information on your rib removal procedure. I am a middle aged male in very good general health. My 12th rib on my right side however is fractured and will not heal. This happened back in early 2023, so I have been dealing with pain on and off for just over over a year now. My primary care physician was confident in our last meeting that my rib would heal on its own, but this meeting was months ago and I’m still struggling with pain. I am not sure he will even agree to this type of surgery, but I just want to be able to live an active lifestyle again and be pain free once more. Which is why I’m reaching out to other specialists outside my network. My two questions are 1. Am I a candidate that you would possibly consider for this type of surgery even tho this is not cosmetic in nature and instead to alleviate pain? And 2. What type of cost would be associated with rib removal of a single (12th) rib? Thank you so much for your time.

A:The key question from my standpoint is where is the rib#12 fractured along its length? I assume this is shown in an x-ray.  That would determine how effectively it could be removed. (get rid of the free floating bone segment distal to the fracture line)

Rib #12 is a very short rib with thin bone so I would doubt it ever could heal back as solid bone so the fact that it hasn’t healed is no surprise.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a Male Deep Plane Face and Neck Lift earlier thus year. I am pleased with the facelift, but not with the chin and jawline.

I am wanting to redo the following:

– Custom chin jawline Implant (Chin Augmentation), I want a longer masculine face (about 3/4 inch down) with a strong jawline (As per before and after pictures included). .

– Upper Eyelids – Eyelid Surgery (blepharoplasty).

I’ve included the following my marked photographs with the dates before and 60 days after surgery, as well as the day of the procedure. I’ve also included before and after photos of third-party custom customised jawline implants to demonstrate my intended outcomes.

A: Thank you for your inquiry and sending all of your pictures to which I can make the following comments:

1) As you have learned, although it was not your primary intent, you can’t lift or defat one’s face into a more defined or stronger jawline. It will merely reveal whatever shape/size jawline that already exists.

2) Your face has thick heavy soft issues, unlike the examples you have provided, so we have to be aware that this is a ‘problem’ in terms of showing jawline shape/definition. Like putting a covering over a ball there is a big difference in how it will look with a thin sheet vs a quilt. In the former you will know it is a ball, it is the latter you would have no idea as to its shape.

3) The method to partially overcome the negative side effects of thick tissues is to expand them or stretch them out. The more you do so the more the underlying shape of the jawline can be seen. But there is a delicate balance between the positive effect of a lot of jawline augmentation and looking too big. Thus more is better to a point. But size tolerance is one of aesthetic preference so in that regard I have attached some potential imaged changes to try and determine your change tolerance.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, i understand i have to gain some weight but i’d never be able to gain enough to get a BBL but i think i could deff gain enough to bring me out of the high risk level for implants if i got hip implants. how much do you think i should aim to gain? i weigh 121lbs right now at 5’10 

also what would high risk mean exactly, what am i at high risk for ? implant rupture or my body rejecting it ?? 

A:You never want to gain weight for a BBL or hip implants as, unless you maintain that weight forever, will simply be lost. But that issue aside it is clear from your pictures you are ultra thin so gaining weight is not a viable option for you even if it was a good idea,

The risk of hip implants in a very thin person is implant edge show not implant rupture (these are solid implants so they can’t rupture) or that of rejection. (infection is possible but not true immunologic rejection) There is no way with a thin subcutaneous fat layer that you will not eventually see some of the implant edging eventually, particularly the lower half of the implant.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have this one face on that shows the issue with a bump on my right side.

Ill take better ones this weekend but from the sides and back it looks fine, seems to just be in certain lighting.that my head shape looks really weird. Could be the camera too, don’t really notice it in mirrors.

Unfortunately my hair is too far gone and have to have a shaved head, insecure about it.

A: Thank you for sending your pictures. I believe you are referring to a right temporal protrusion seen above the right ear. (see attached picture) That area of excess muscle mass could be reduced from an incision in the crease of the back of the ear.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My goal is to have the back of my head, flat without any dip or separation.

A:This is a back of the head problem that I have seen many times. This is due to an excessive of bone and an overlying roll of scalp tissue, both of which have to be removed to get a smoother transition from the back of the head into the neck. There is the tradeoff of a fine line scar across the area and I would need a back of the head picture to show you its location. But as a general rule its length is the same as that of the scalp roll.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have been aware of my plagiocephaly since I was 12 and I wish I had neither recognized nor investigated it. Since then, I have had the same haircut, which I cut myself. But now, approaching 30 years old, I am tired of buying hair products, using straighteners, and spending so much time in the bathroom.

So, I would like to have cranial symmetry and a nice skull shape like my mother’s. I don’t really care about facial symmetry, haha. I would like to go to my younger brother’s hairdresser, get the same haircut as him, and travel with him without having to pack hairsprays, straighteners, or anything like that. I want to go boxing with him and wear a helmet on my head (I can’t stand any pressure on my head, it’s like having tickles, I move away from the stimulus at lightning speed). Sometimes I feel ridiculous, to be honest.

A:It appears he has a right flat back of the head, usually the most significant deformity from plagiocephaly, for which a custom skull implant is the best method currently to treat it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon