Your Questions

Q: Dr. Eppley, What are your thoughts on fat grafting? Specifically in the chin area? Someone mentioned that it dissolves and others say it doesn’t. I am thinking of a chin implant but have a deep mental crease and was wondering if fat grafting would help.

A: If you are concerned about a deep labiomental in the chin, it doesn’t matter what the method of chin augmentation is (fat, implant, bony genioplasty) it is going to get deeper.

For chin augmentation fat does have a high rate of resorption and should only be considered when the amount of augmentation is needed is minor.

The real role of fat grafting in the chin is for the deeper labiomental fold when chin implant augmentation is being done to soften or mitigate the deepening effect on the depth of the fold.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I want to know if you do a procedure to reverse a buccal fat removal  I want to recover the round of my face. Here I have before photos. I wanted to reduce other parts, but now I just want to recover the rounded face.

A: There are two methods of buccal lipectomy reversal….fat injections and enbloc fat graft insertion. Given the scalp of your fat loss based on your pictures the fat injection method seems best given the broad area of fat loss.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, i have a bad facial asymmetry. what do you think i should do ? what procedures. my left side is asymmetry , i recently had a rhinoplasty but it didn’t go as expected.this is how I look.

A: The two most important changes to make in your facial asymmetry is to correct the jawline and the nose (again). These two would do the most to straighten out your face.The two most important changes to make in your facial asymmetry is to correct the jawline and the nose (again). These two would do the most to straighten out your face.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I have recently gotten TMJ replacement surgery, is it possible to place jaw implants at my gonial angles that would lessen the jaw angle? On my one side my ramus doesn’t drop down very far so I have a very steep jaw angle. How far can implants help with this, it would need to be significant is this possible ? If so I would like to schedule a consult in the new year

Picture attached was before surgery but the angle hasn’t changed.

A: The simple answer is that it is possible to place custom jaw angle/jawline implants with TMJ placement implants in place.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, For a while now I have been trying to remove all of my tattoos with laser and it is definitely working! The thing is, although they are black, as with every tattoo,  full removal could never be guaranteed till the end. 

That’s why I decided to ask an actual reconstructive surgeon to see if a THEORETICAL plan b could work. I repeat that it is THEORETICAL and I would just like to understand if the idea could be carried out on paper, even if it doesn’t translate precisely in real life, due to complications or risks.

I will slice my plan in two sections:

1)The first 3 tattoos  (the gun, the letters on the hand and the numbers):

• Do you believe those tattoos could be excised or serially excised?

2)The other 3 tattoos (the one on my neck, the brain on the shoulder and the jaguar on my stomach).

• Since they are  larger, could I ask if tissue expanders could THEORETICALLY be placed, so as for the surrounding skin to stretched enough for the tattoos to be excised.

I know that expanders have been used on the stomach, the shoulder area and the neck for burn reconstructions and I am also aware that they carry particular risks, especially on the extremities, such as ruptures, necrosis, infection and etc. Taking the obvious risks aside, which I have fully accepted, could this plan be done in the worst case scenario?

It probably won’t come to that at all and I will exhaust of my efforts on laser, before even considering surgery. But just knowing that such options exist, would give me so much relief and allow me to not depend only on unpredictability.

A: Your tattoos are too big for any method of serial excision. The scars they would leave by so doing would be worse than the residual tattoo pigments left by the laser treatments.  You will have to stick with laser treatments and see how much they can accomplish.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley,  I went for a consultation a few months ago to see if I would be a candidate for either jaw surgery, midface implants, or both. I had figured that I probably would benefit the most from infraorbital/submalar implants to even out the projection of my mid face, and the Surgeon checked with his partner in practice that does the jaw surgeries, who said “home run” on the idea of just doing the implants, plus a chin implant. They were very informative, and it will be quite a while before I would end up having it done, but I wanted to check with your practice since you are the most well known for the customized implants. So, my concern is basically the middle of my face. Would be grateful to hear your thoughts thank you!

A: To look at various facial reshaping changes and do imaging (which is a critical assessment…you never just eyeball potential face changes and call it a ‘homerun’) requires a consultation.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q:Dr. Eppley, I had double jaw surgery for sleep apnea recently and my cheeks are now out of harmony with the rest of my face and my jaw is fairly narrow with a fairly short ramus so it looks a bit strange and I think it would make me a very good candidate.

A: it is fairly common to see patients for custom jawline and infraorbital-malar implants after Bimax surgery, particularly for OSA. The large maxillary movement leaves the upper midface behind and the large sagittal lower jaw movement can make the lower facial third look too narrow.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am also concerned if silicone would result in aesthetic differences as they’re softer than PMMA or PEEK. Would the results not have as defined of a look around the jawline or the mandible borders?

A: There is no difference in the feel or appearance once implanted on the bone between solid silicone and PEEK. The concept of silicone being soft and not creating well defined facial shapes is false.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Hello! I’m interested in shoulder reduction surgery but had a few questions. One, I’m a graphic designer. How soon after this surgery would I be about to go back to doing my work? Secondly, what are the long-term impacts on the shoulders? Should I have any concerns about that…?

A: In answer to your shoulder reduction questions:

1) Since the first 2 weeks after surgery one has to keep their elbows close to their side as a postoperative restriction (short arming it)  I assume that you could not work as a graphic artist. (although maybe you could) After two weeks one can move their arms out to 45 degrees in which I assume there would be no problems working then.

2) There are no known long term issues with shoulder function. The amount of clavicle length removed (2.5cms) isn’t enough to do so.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, Can you 3D print Brad Pitt’s Head shape? Is it possible to take it as an example, file the excess bones and add the missing parts to get the closest image?

A: Many patients use other people’s head and face shapes to try and emulate. Since we don’t have their 3D CT scans I have to guess what those bone shapes would be from which the 3D implants are made.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, The fundamental thing I would like to resolve is the asymmetry between the two sides of the face, in particular the eyes and the jaw. I would like to understand the causes of facial asymmetry and whether it is possible to correct it, and with what procedures (for me it is a great discomfort.

A: Like most facial asymmetries they are usually complete affecting the entire side of the face if you look close enough. The eye and jaw are usually the most apparent part of the asymmetry and both can be improved significantly. The left jaw asymmetry is treated by a custom designed implant based on the shape of the opposite right side. The left eye asymmetry is usually treated by a custom orbital floor-rim-cheek along with adjustments to the eyebrow, brow bone and eyelids.

But the first place to start in facial asymmetry is to get a 3D CT scan to assess the differences between the two facial sides as well as serves as the basis of the custom implant designs used to treat it.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I was wondering what could be done for my pointed head shape? Could the area circled in red in one of the pictures be burred down to reduce the peaked look?

A: While sagittal ridge skull  reduction can be done in your case its impact on improving the peaked head shape would be very modest. The more profound change would come from parasagittal augmentation to raise up the sloped sides of the head along the sagittal ridge line. It may or may not be combined with sagittal ridge reduction based on what computer imaging shows us about its effect along with parasagittal augmentation.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I am struggling with lower lip incompetence. I did bsso and a sliding genio 4 months ago. Half of my lower lip and chin are still numb. The numb side of my lip is also a bit crooked. Talking and eating is fine. I dont have much tightness except from my scar tissue inside my lower lip. But I cant seem to close my lips at rest. I just had my braces taken out. And really hoped for improvement. But it did not get better. Will this go away? Or is this my final result?

A: More healing time will answer the question of the true final outcome, like up to one year after the surgery. I would expect much of the numbness to resolve but the lower incompetence may ne another matter.

Dr. Barry Eppley

World Renowned Plastic Surgeon

Q: Dr. Eppley, I read in your blog that you mention for someone with high gonials, using a widening jaw angle can make the face look heavier/ bulkier. How does that compare with adding vertical lengthening, as I imagine that also seemingly would add heaviness to the face?

A:That has to be determined on an individual basis by computer imaging, But as a general statement widening truly high jaw angles can make for an undesired change. Vertical elongating the high jaw angle has a lowering effect in the frontal view which may or may not be aesthetically favorable. Everyone’s facial shape is different as well as their aesthetic objectives/tolerance so it is not as simple as generalized statements.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, i’ve always struggled with my appearance simply because of my high hairline and my wide forehead. kids used to call me an alien in middle / high school. i really want to get a forehead reduction along with a bilateral posterior temporal muscle reduction.

A:  Forehead reduction in you poses some unique aesthetic considerations. With a high frontal hairline and a wide bony forehead and large temporal muscles you have astutely pointed out that the two are linked. You can’t change one without changing the other…meaning if you lower our hairline your forehead will look even wider due to the width of the bone and the width of the temporal muscles. Conversely if you just reduced the temporal muscles the hairline would look even higher.

As a result a frontal hairline advancement needs to be combined with a reduction in the width of the bony forehead (which can be done through the hairline incision) as well as temporal reductions done through postauricular incisions. (posterior temporal muscle removal, anterior temporal muscle transposition)

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My buccal fat pads were removed when I had my LeFort surgery was done.  I wanted to get your opinion as to whether it’s possible to restore them using a fat graft from some other part of my body.  I don’t want to use synthetic injectables as I have a lot of concerns about them.  I’d only want to do this if Dr. Eppley thinks that he can achieve a moderately satisfactory correction of the issue.  I know there’s no way to actually reverse this buccal fat pad removal, but I was wondering what the state of the science and surgical practice was nowadays regarding what can be done to mitigate the loss.

.A: Buccal lipectomy reversal can be done by two methods….injection fat grafting and en bloc fat graft insertion. The fat injection method is as straightforward as it sounds and is done on the conventional injection method with the caveat that it is done from an intraoral approach given the depth of the buccal fat space. En bloc fat grafting is where a solid piece of fat is harvested, the buccal space reopened intraorally and a sold fart graft (83ccs in volume) out back directly into the buccal space. This would certainly be viewed as the anatomically accurate buccal lipectomy reversal approach.

The differences are that the fat injection method is minimally invasive and harvests the fat by liposuction but at the expense of the unpredictability of how well the fat will survive.

The en bloc or solid fat grafting method requires an intraoral open approach and harvests a fat graft by excision but with a more predictable fat graft survival.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I want to get large deltoid implants. I have attached some pictures of some results that would be my goal.

A:Those are subfascial deltoid implants, you just can’t see the scar by the AC joint. The key about implant thickness, besides the concept of what will fit, is that the pocket location will have a major play on the thickness/projection  of the implant used. For the subfascial pocket you can get a 3cm deltoid implant while for the submuscular pocket it is 1.5cms.

The other important concept is whether one is using standard CCB implants or making them custom. Standard CCB implants have a maximum projection of 1.5cms while customs can be made to any projection.

The most relevant issue that your images show is your tolerance for the type of aesthetic shoulder change that may be acceptable. Some patients may look at that before and after and think it looks too squared out/unnatural while others may find it acceptable. I am going to assume you are the latter?  That tolerance will then guide the type of implant used and pocket location for it.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am looking to get my temporal muscles reduced. (see pictures)

A:You have distinct pattern of temporal muscle enlargement that involves both the anterior and posterior temporal zones. The relevance of that distinction is that each zone is treated differently as the thickness of the muscle and the shape of the bone underneath it are different. (see attached diagram) The posterior temporal area is treated by complete removal due to the direct access from behind the ear. This is where the muscle is the thinnest and the underlying has a convex shape. The anterior temporal area has very thick muscle and a deep bony concavity underneath it as a result. It is not possible to completely or even partially cut out the muscle in this zone nor would you want due to negative impact it would have on jaw function. The anterior muscle zone is treated with a transposition technique rather than excision which helps reduce its fullness to some degree but not as effectively as the posterior zone excision does in that area.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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