Your Questions

Q: Dr. Eppley, I am trying to achieve a more masculine/sharper jawline/chin while not overly looking fake and getting rid of the deep crease as much as possible.

A:Thank you for sending your jaw thrust pictures which is a great way to simulate how much vertical chin lengthening a patient wants. This demonstrates that you are in the 14 to 16mm range ((at least) which puts it clearly in the vertical lengthening osteotomy procedure. With that amount of bony lengthening the labiomental fold will get less deep as the soft tissue chin pad beneath it stretches down. It is will not as shallow as is shown with the jaw thrust because the movement of the whole lower jaw and the teeth flattens the fold.

Similarly the jaw thrust artificially augments the entire jawline behind the chin which the vertical chin lengthening will not do. To create that effect a custom jawline implant needs to be down with the chin osteotomy for a total jaw augmentation effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would be interested In your temporal reduction surgery and optoplasty. Would you be able to do this in one procedure? Reduction to muscle above the ears, making the head a bit thinner on both sides. Then having my ears pinned back in conjunction with this.

A:Both temporal reduction and setback upper otoplasties can be performed during the same surgery. Besides the obvious efficiency of doing them together there is almost a need to do so with ears that stick out as temporal reduction will likely make the ears look even more prominent.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I wanted to know if you did custom zygomatic arch implants that offer less than 3 mm of projection on each side. Perhaps 2.5 mm or 2 mm?

A:In custom implant designing you make the implant have any dimensions the patient needs to achieve their objectives. The limitation in terms of ‘smallness’ is that the implant has to have a thickness of at least 2mm so it can actually be made.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Last year I had a malar and premaxillary implant put in as I had a very sunken face from previous pr molar extractions. My surgeon promised me that this would not have any effect on my nose and that if I didn’t like it I could remove them and everything would eventually go back to pre operative state.The implants completely further destroyed my face and really made my nose look wider and thicker so I took them out 4 months after. Now 13 months after I am devastated over how my nose is completely destroyed. I had the most perfect nose and I was very particular about not wanting any changes to my nose and if that would be the case i wouldnt want to proceed with the surgery. The surgeon further reassured me that it would not have a negative effect and would just serve as a filler in the area. The surgeon is gaslighting me telling me that he has not touched my nose during the procedure and that he doesn’t know what happened to it. He has been very strange with different answers and even stopped to answer me completely at one point. I don’t know where to turn for answers since he refuses to give me answers. Since he removed the implants e hasn’t even cared to invite me back to the office or take a look at my nose once and he just keeps saying that he doesn’t know what happend. I have only managed to find answers on your website so far and I am devastated to see that for this procedure you have to in fact detach the nose on several places to fit the implant and my surgeon just won’t admit to it. Please help me, what can I do to get my nose back?

A:In any form of intraoral midface surgery, whether it be a LeFort osteotomy or a midface implant where a complete soft tissue degloving from the bone is needed, there can be some potential changes to the nose particularly that of the nasal base. (premaxillary-paranasal area )  The nostrils can become wider as the soft tissues have become detached and retracted. This potential anatomic issue has been known for decades and is why a variety of protective procedures during closure from these procedures have been employed to try and prevent these adverse nasal base changes. (e.g., alar cinch suture, V-Y musculomucosal closure) Even in ‘simple’ paranasal implants the nostrils have been shown to increase in width by 1 to 2mms.

Postoperative management of the wide nasal base can be treated by external nostril narrowing techniques or even inraoral cinch sutures. Ironically they are more effective when combined with some pyriform aperture augmentation…even though that was the original source of the problem. (the soft tissue degloving was not the implant per se)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I hope to try for 7.5cm and want the biggest size possible but see from FAQ’s it may be best to start with something a bit smaller and then replace 3-4 months later with the larger size. What would be the cost of going that way? 

A few questions if I may: 

•  how does one do testicular exams/health checks  with the displacement method?
• Of course I want as large an implant as possible and want to avoid the testicles dropping back into view. What is the frequency/risk of that happening and how does one resolve it? Presumably another procedure? 
• I do pumping for penile physio and I assume I can continue to do so after the procedure?
• How long would I need to stay in the US after the procedure to come back for follow up reviews and checks?

That’s all for now, most grateful for thoughts. 

A:1) It is better to be safe like 6.5 with a lower risk of complications.

2) Whether it is a displacement or wrap around technique a testicular examination is more challenging. But at least with the displacement method an examination is possible as opposed to the wrap around method in which it would be impossible.

3) Testicular show (partial/limited and is up high) with the displacement implant method is not common but possible. Should it occur there is no effective treatment for it.

4) You will be able to pump after the surgery once you are well healed.

5) After 48 hours you can return home.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello. I have a webbed neck and im looking into what options i have for correcting, i do also have a very low hair line which i’ve read somewhere that can also be corrected. My whole life i’ve struggled with this and my self confidence so im very excited to hear back and have a bit more of an understanding of what can be done. 

A:While webbed neck surgery can provide improvement in the shape of the neck (not quite as wide) I would be cautious when using the term ‘correction’ as achieving a completely normal neck shape is usually not possible. Also webbed neck surgery offers little to no improvement in the low hairline. The outer position of the low hairline may change (move inward a bit on each side) but its actual low vertical position is not altered.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want toi get rid of my perioral fullness that occurs when I smile…but does not exist when my face is at rest.

A: What you are essentially asking is to treat a dynamic problem with a static procedure. Surgery is almost always performed to correct facial tissues at rest not if they just appear from active dynamic facial movements. The point being is that one may have to trade-off a contour indentation at rest (which does not now exist) to partially reduce the fullness when you smile. It is a question of trading off one problem for another….it is just a question of which one you see as worse.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am writing to you because I recently had a chin implant infection, after a chin implant and mandible implant surgery. I am  now3 months post op, my surgeon had to remove the chin implant and the infection was resolved for a bit, then it seemed to have returned. I’d like to see if you possibly had any input on my case to see if there was a way me or the surgeon could do something to prevent infection upon re implantation. Here’s a quick timeline:

•I had 2 size medium stock implantech widening mandibular implants implanted intraorally and a “custom” chin implant – a stock anatomical chin implant size medium sutured to a stock vertical lengthening chin implant size medium inserted through the skin (under the chin). This “custom” implant was the suggestion of my surgeon to give me vertical and horizontal chin projection. The “custom” chin was anchored with 2 screws and the mandible implants were anchored with one each.

• The surgeon doing this had a good track record with implant infections, he claims he’s done around 4,000 before and never had an infection in his career. He used the implant sizers as developers for the pocket, inserted the chin through the skin, and applied vancomycin powder on top of the implant before closing.

A: I can only make some general comments in regards to your case:

1) There are only two reasons the infection is not fully resolved by the chin implant removal…1) all of the chin implant is not fully removed or 2) the jaw angle implant(s) behind the chin have also become infected and are draining anteriorly through the path of least resistance. (chin implant pocket/incision)

2) Almost all implant infections are the result of intraoperative inoculation….the mouth can never be sterilized completely…this is the risk of an intraoral implant surgery. It doesn ‘t matter if one has done 4, 40, 400 or 4,000 implant surgeries it is simply a matter of statistics….eventually it is going to happen to someone. This is never the result of what the patient did or didn’t do.

3) Once an implant gets infected…it is over. It doesn’t matter what maneuvers are done to try and treat it. The biofilm can not be eradicated, only implant removal can solve it.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, To confirm my understanding: there is no significantly increased facial trauma risk with titanium or PEEK facial implants, with respects to combat sports, as the “stress-shield” effect is irrelevant?

I am considering this procedure and want to ensure I understand whether I would need to give up boxing afterward with either titanium or PEEK implants.

Thank you for your time and help

A: It doesn’t matter what the facial implant material is…silicone, Medpor, PEEK or titanium…they all will respond the same to external forces.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley,  I am researching the best options for facial implants and have a couple of questions regarding material suitability and safety:

Given that PEEK has a smaller elastic modulus mismatch compared to bone than titanium, does this make PEEK implants a better choice for reducing risks associated with stress shielding?

If I were to choose titanium facial implants, would it be safe to participate in high-impact sports such as boxing, or does the rigidity of titanium make it too dangerous in cases of facial trauma?

Thank you for your insights and expertise on this matter. I look forward to hearing your thoughts.

A: You are overlooking the most important features of any facial implant material….how easy is it to place and subsequently remove/modify/replace. Given that the revision of all facial implants is in the 30% to 40% range this implant feature becomes the most important material feature.

Your biomechanical analysis of rigid implant materials is irrelevant clinically. That only has validity if the material is free floating and unattached or on a benchtop. But when the backing of the material is bone onto which it is placed this equalizes all material biomechanical features.

Stress shielding is an irrelevant issue on the face in which the bones carry limited stress loads. The face is not like the axial skeleton and is not an orthopedic bone site.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, ! I’m 59 years old and considering getting a face/neck lift, but don’t really like the idea of hairline scars. My question is, if I got a 3D printer skull implant to correct my flat head and tissue expanders weren’t used would that also give me a neck and face lift? I’m also considering getting cheek implants where my face was crushed at birth with forceps

A: No size of skull implant is ever going to create the effect of a facelift. In very large skull some patients may experience a browlift but its lifting effects will not extend down into the lower face and neck.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I was wondering if a genioplasty could be be performed shortly (I.e. a week) after Hyaluronidase had been injected in the chin area to dissolve filler – would any soft tissue inflammation affect the outcome of surgery?

A: Hyaluronidase is an enzyme injectate that it placed into the soft tissues while a genioplasty, which I interpret to mean a bony procedure, lies beneath it. Thus the injections wold not interfere with the bony healing whether done before, during or after the surgery.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am inquiring about testicular implants. I take TRT as I am 61 years old and have also had penile enlargement surgery. My testicles now feel small as a result – smaller than before – and this bothers me badly. I am looking to increase their size through implants to the maximum level of safety and practicality. 7.5cm or larger if possible, using the most natural material (gummy bear) and as attached to the existing testicles rather than displacing them (although I will take your advice on which way is best to proceed safely and achieve my objectives).

A: With small testicles due to hormone supplementation and aging you definitely do NOT want the wrap around testicle implant enhancement method. Small testicles have a high incidence  of slipping out of the implants after surgery…. a problem that has not yet been satisfactorily solved as of yet. The displacement method does not have this problem and is very effective as long as the implant size is at least 70% of the natural testicle size. Usually this means at least 6.0 to 6.5cm size. I would be cautions about a size of 7.5cm, as when placed on each side, the volume they create may pose problems for incisional closure in some patients. It would have to be seen whether you have a scrotum that is capable of safely handling that implant size.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am 44 year old female. I don’t like how my face asymmetry is noticeable. I want to aquire more symmetrical features on my face, eyebrow, eyes, cheeks. I want to look normal. Can you help me?

A: Like all facial asymmetries the first step is to determine the most important facial features to try and improve that would make the biggest difference. In your case that appears to be the right eye area as you have an obvious vertical orbital dystopia. (VOD) This involves the eyebrow, eye and cheek area. The second step is to get a 3D CT scan so the differences between the two orbital boxes can be determined from which a custom orbital floor-rim-cheek implant can be designed. While the implant is not the only component of the correction (browlift and eyelid changes are also needed) it is the foundation of VOD corrective surgery.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Is there anywhere to see more before and after pictures of angles of the patients with the jaw implants and which type were used besides the website?

A: How do other patient’s results help you understand what you may need when every patient’s jaw shape, soft tissue thicknesses and aesthetic goals are different? That is a very misleading way to try and make that assessment. It has to be determined on an individual basis using computer imaging.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Are malar implants only done with synthetic material? Can you use an autologous graft like cartilage as I am prone to inflammation.

A:While one can use autologous and allogenic tissues for cheek augmentation the amount and size of the graft material that is available (by harvest ot tissue bank acquistion) limits their potential effectiveness. In otherbwords for very small amounts of cheek augmentation they make be effective. In some patents cheekbone osteotomies can be used if the cheek augmentation goal is one dimensional. (cheek widening)

In essence implants allow any type of dimensional cheek augmentation change and the control of the result is preoperative selection. Conversely grafts and osteotomies have more limited effects their harvest size will control the cheek augmentation effect.

These are general statements about cheek augmentation materials. How all this applies to youis  knowing what your cheek augmentation goals are compared to what your cheeks look like now.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had genioplasty + bone graft for chin advancement and lengthening and jawbone osteotomy done in Korea about 11 months ago.I saw some improvements but there were a couple of unsatisfactory results:

In terms of the chin:

1. there is a bony gap now in the chin from the genioplasty

2. there is some asymmetry of the result

3. there wasn’t as big of a difference as I hoped so the chin is still recessed, and length is still not as proportionate

Jawline:

4. gonial angle is not as visible now and jawline is less prominent

I am not looking for dramatic results but was considering getting custom chin and jaw implants to address these issues to improve the results but am also open to any other options recommended that are available since I don’t need dramatic results just a good solution that will work long term to reach my aesthetic goals of:

1. more chin projection (maybe just 4mm) and addressing asymmetry (priority). This is also to make the mouth protrusion look less noticeable but would be open to jaw surgery if it is a better fit. However, After consulting multiple spots I have been told my case is not severe enough for jaw surgery and I should consider just implant, or genioplasty + orthodontics.

2. clearer jawline and angle (not as priority depending on costs)

Let me know your thoughts and what you think the available and best options are.

A:You have had prior V line surgery with the tradeoffs of too much jaw angle bone removed, bony gaps/irregularities in the chin osteotomy and desire for some additional horizontal chin projection. To make these improvements now these can not be adequately improved by further bone surgery. This would require a custom wrap around jawline implant to make all the needed improvements. In other words overlay the bone to get the increased chin projection, a more evident jawline and to smooth out the inferior border.

Such secondary V line surgeries are common in my practice. The custom design approach allows control of all desired changes preoperatively because of the 3D design process.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I believe I had plagiocephaly as a kid on one side of my head is a little pushed in which pushes half of my entire face forward. Teeth slanted, Jaw asymmetry, chin asymmetry, one eye bulging, uneven ears, one side of head sticking out kore, nose asymmetry. How bad do u think it is. Is it just me or it’s bad? Give me on a scale of 1-10. 10 being the worst asymmetry and 1 being basically symmetrical. Thank You

A:I have no opinion on rating the severity of your plagiocephaly. What matters is how you feel about it and whether it is significant enough that you want to do something about it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had a sliding genioplasty about 4 months ago, and have become increasingly certain that I have lower lip contraction, as I have to use force to push my lips together and there is a lot of tightness in my lower lip area. It has also become significantly smaller than it was prior to the surgery, which has really affected my smile as well. I was wondering about the VY mucosal advancement procedure that you wrote an article about – do you currently perform such surgeries, and if so how much would you estimate the cost to be? Thank you in advance.

A: A vestibular release and dermal-fat grafting is what is needed for lower lip tightness after a sliding genioplasty not a V-YT advancement which is an ancillary procedure. not a primary one for that problem.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in getting testicular implants. My main reason is I am not currently happy with size of my natural testicles and if I’m to be honest I have yet to see an implant size that I am happy with. That is why I come here, in theory what is the largest implant you could possibly do? I am looking for something truly large a lot larger than extra large implants that I have seen.

A:The custom testicle implants that I have done range from 6.0 to 8.5cms in size. The question in large testicular enhancements is no what can be made but what size your scrotum can accommodate. It is not a design issue but a  tissue tolerance issue.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, can you remove Bellafill from the cheeks? I had Bellafill injected and the injector put it in the cheeks which I didn’t ask for. I wanted tear troughs only. They look really off, it was put in my medial and lateral cheek. One doctor said it can’t be removed from these areas, but I refuse to believe nobody can help.

A:There is no effective method to remove the PMMA micropheres in an area like the cheeks. Excision is the only method for acrylic particle removal and that is certainly not going to be done in the cheek area without considerable external scarring.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve seen your pelvic plasty and shoulder width reduction results and think they’re quite impressive, but I’m trying to achieve the inverse as I am female to male transgender, primarily a narrowing of the hips. I’m aware that the logistics of reconstructing the pelvis would differ significantly from simply adding an implant onto the existing structure and quite aware of the consequences it could have on my mobility, but I’m curious as to whether any professionals would be willing to perform such a procedure on a patient for cosmetic reasons. 

A: You are referring to iliac crest reduction for the hip width which does not cause any long term mobility issues in my experience. It is generally limited to 1 cm per side at the maximal crest width.

For the shoulder there are clavicle lengthening or deltoid implant procedures to make the shoulders wider. Each has their advantages and disadvantages.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, are there skull reshaping cases where a blood transfusion is necessary? I believe that transfusion of other people’s blood is inherently dangerous. (I am no problem with autologous blood donation.)

A:There is no significant blood loss in any aesthetic skull reshaping procedure. A blood transfusion would never be needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am getting a hair transplant in Turkey next year and was wondering how long after it would be safe to get a forehead implant without damaging the hair follicles.

A: I would wait 6 months after the hair transplants so the newly transplanted hair is fully growing and healthy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Last year I had mandible contouring that was especially aggressive on the right side due to bony overgrowth. Since then I’ve been hoping my lower lip asymmetry would resolve but has not. I feel the muscle pulling my lip to the right and down. My right lower lip kinda feels swollen. If I lay on my right side I drool a little bit at times. Luckily I don’t have functional problems eating, drinking. I want to try Botox and lip filler for cosmetic improvement but I want to know if there’s a permanent solution? Would a neurologist be able to fix this?

A:What you are describing is classic weakness/paralysis of the marginal mandibular branch of the facial nerve. If you are more than a year out from the surgery no further improvement in motor function can be expected. There is no method to restore motor function to that nerve branch. Botox may help weaken the good side for improved lip symmetry to the paralyzed side. Fillers can temporarily add volume to the smaller vermilion or a permanent lip volume restoration can be done with a vermilion advancement. I would always start by trying temporary measures (Botox and fillers) first.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I  have a small mouth like to get it widened if possible please send me some info about the procedure and the cost of it.I also would like to have a lower face lift.

A:Thank you for your inquiry and sending your pictures. With a small and downturned mouth with sagging facial tissues I don’t think you can get mouth shape improvement without addressing the sagging facial tissues as they overhand and pull the mouth corners down. Thus any efforts at mouth widening/lift is linked to the lower facelift.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in the collarbone lengthening surgery. A few years ago, I had a fall and broke my collarbone. The fracture shortened my collarbone by an inch and since then, my back, shoulder, and arm hurt.

A: Untreated clavicle fractures are well known to shorten as they heal. Clavicle lengthening would certainly be the logical approach to treating the problem. While clavicle lengthening surgery for aesthetic purposes is limited due to the soft tissues of tiger shoulder girdle, in reversing shortening from fractures the shoulder tissues are used to the length that it originally was. Thus, in theory it should be successful. I would need to see x-rays of both shoulders and presumably the osteotomy site would be at the fractured area.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I wanted to ask a few questions before I schedule a virtual appointment. I’m interested in wraparound testicle implants, but I’m from Poland and if those are custom, I guess I would have to come to the clinic to measure everything or is there another way to do this ? Next thing is, I would have to do blood tests of course, could I do them in Poland and send them to you via email or should it be done right before procedure and here is my next question, if some of the results came back not so good would this disqualify my from the procedure ?

A:I shy away from using wraparound implants in testicular enhancements due to the risks of postoperative separation. I prefer the side by side technique where that risk does not exist. Those seizes are based on an estimate of your natural testcile size which can learned from measurements or an ultrasound.

Whether blood tests are required before surgery depends on your age and your health…none of which I currently know.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, As you can see, my son’s face is not symmetrical. I think the most serious part is his slanted jaw which appears to contribute to differing eye level. Other than that, one side of his cheek seems to be slightly larger than the other. Many doctors I’ve consulted have suggested that this might be due to an injury from a fall during his childhood. However, to the best of my knowledge, he has never experienced such an incident. I would greatly appreciate your insights into the possible causes of this condition and most importantly, your recommendations on surgeries or treatments to consider. Thank you

A:This is a congenital severe facial asymmetry whose in utero cause will never be known exactly. The entire left side of his face is smaller than that of the right…making every left facial feature at a different horizontal level than the opposite side. I would agree that the jaw asymmetry is the most affected and also the faciakl area that can get the greatest improvement. He is in need of double jaw (orthognathic surgery) which is a common procedure that can be successfully performed in  most countries and at least in the regional area.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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