Your Questions

Q: Dr. Eppley, After my cheek implant removal I had a midface lift to help with the cheek sagging. While the mid-face lift did help reposition the deeper layers of my face, the more superficial soft tissue  and fat remains significantly lower than the deeper layers of muscle on my face. 

I’ve been using PDO thread lifts a couple of times a year to temporarily lift this tissue, and while I love the results and it perfectly addresses my concerns, it doesn’t last and isn’t cost effective long term. 

I’m wondering if an intraoral incision with the use of an Endotine or sutures could reposition and secure the soft tissue to the SMAS for a more lasting result. I believe it was this layer that was not addressed during my mid face lift and it was this layer that got disconnected when pockets for the implants were created in my face. 

A:The Temporal Endotine Midface Lifting technique is like any deep plane facelift approach…it elevates the deeper tissues as its effect are at the subperiosteal plane level. Your PDO threads have been effective because they are at a superficial tissue level which the Endotine device will not affect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’ve been just super insecure about my lips for awhile  they’re just not wide and I feel like it just throws my face off. My questions are how much is pricing typically and is this a life long thing or will it go away after awhile. Thanks

A:You are undoubtably referring to mouth widening surgery. I would need to see a front view picture of your face to do imaging to see how much mouth width can be added. Mouth widening surgery creates permanent results but also some small permanent scars as a result. Thus the quetsion is not about the permanency of the increased mouth width but whether the permanent scars to do so are a good aesthetic tradeoff.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m interested in a sliding genioplasty. My occlusion or bite is fine( as far as I know and have been told.My chin has never been operated on or i.e. a virgin chin that I think needs only minimal to moderate changes in order to harmonize and balance my face. 

Having said that;I think I have a mild to moderate short face syndrome as evidenced by these pics taken by max surgeon on Sep 2024. He claims I have no vertical deficiency at all based on his software but he agrees that I have about a 4 to 5 mm horizontal deficiency.

It’s confusing and frustrating because about 9 years ago another max surgeon did no cephalic study but just eyeballed me during the consultation and confidently proclaimed 4mm to 5mm horizontally but about 8mm to 10 mm on the vertical but he also said he would back the estimate it with a study.

What do you think? I’m just trying to be logical, prudent and practical here.

A:Like all aesthetic issues it is what the patient perceives,  not what numbers/measurements or a doctor says is so. From that perspective I like to dive into imaging and see how the patient responds to some changes. (see attached chin augmentation changes which includes vertical lengthening) One can debate about about how much vertical lengthening is desired and how to do it…but that is not initially relevant. The first step is to determine if any amount of vertical chin lengthening is desirable from your perspective.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I have a webbed neck and would like to learn more about the surgical procedure. I have not been diagnosed with Turner’s Syndrome, however I was also never tested. I am very self-conscious about it and would love to improve the look and functionality of my neck. 

A: First, webbed neck surgery is done to improve the appearance of the webs. It does not, however, improve the function of the neck. (e.g., range of motion)

Thank you for sending your pictures. Non-syndromic webbed necks, also known as mosiacs, usually have stiffer or non-flexible tissues. Thus, even though the smaller neck webs would seem to be the most improvable, they usually are the most resistant. That is my general experience based on your pictures alone. But the effectiveness of webbed neck surgery ultimately depends on how mobile the posterior neck tissues are which obviously can’t be assessed in pictures.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, My goal is to do this surgery. I hope you can help me to get red of rejection among people . Honestly I live hard live because of my skull shape. I wonder could you fix all this destruction on my skull. How much the possibility to have a good shape after surgery?

A: What you have is classic plagiocephaly with a left craniocoliosis rotation in which the left back side of the head is flatter and the left temporal and forehead is more protrusive/pushed forward. For the back of the head a custom skull implant it out is the standard approach. For the front of the head there are two options: 1) reduce the left forehead or 2) build up the right forehead. That choice is based on what the patient sees as the best aesthetic appearance.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi, I had maxillofacial surgery twice to increase size of chin. There is something that is missing on the jawline. I was thinking that an implant may help

A:I believe what you are saying is that you have had two bony genioplasties to increase your chin projection. In so doing what often happens is that a bony stepoff develops at the back end of the osteotomy cut from the advanced bone. Such a bony stepoff becomes more evident the larger the chin advancement becomes. You are correct in that the management of the bony stepoffs requires implant coverage. The only question is how best to make an implant for both to do so. A custom implant design is always the most accurate way to do it. But before any treatment option is considered a 3D CT scan of your chin should be done to have a complete visual understanding of the jawline defects.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q:Dr. Eppley, I would like wraparound testicle implant with the most size because it is my the trauma of the young man having small testicles.

A:Because of the numerous complications from the wrap around testicle concept (implant separation)  I only use large side by side implants today (6.0cm or greater) which have none of those issues. They work by displacing the appearance of the smaller testicles up and back up out of the way.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had my brow bone shaved down four years ago and feel like it is not proportionate and throws off my eyebrow shape and doesn’t let them fully settle on the bone for a relaxed look. This is the before and after – while I am happy with my side profile I want to explore possible options to improve my front profile.

A: After such a brow bone reduction the question would be what can be done secondarily that only affects the front view and not the side view? As you have learned from this past procedure every facial bone reshaping procedure has multi dimensional effects that may have variaboe aesthetic benefits when seen from different facial angles. In other words if you restore some medial brow shape it will change the side profile.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I wanted to follow up if there are any planning images to be shared so far ? As you know I recently had my stage 1 scalp expander put in and I’m eager for the design process to unfold. Furthermore, when I spoke with Dr. Eppley in person, he mentioned the goal of us is about 5/8″ of protrusion, it seems really minor from a dimensional perspective. For previous patients such as the attached, it seemed more of a drastic change like closer to ~1″? Am I correct to make these assumptions?

A:These are partially incorrect assumptions. Skull augmentation is mainly about volume displacement rather than one specific linear measured point. Think of your head as a balloon and not a ruler. It is a large curved surfaces area rather than one flat surface. Thus skull implant designing is guided by implant volume which does come from its shape and various thicknesses. But in the end the volume that the scalp can contain (in your case the tissue expander) will determine the maxmum projection of the implant. To provide some insight in thar regard a one inch or 25mm thick implant would probable be an implant volume of 300 to 325ccs. 5/8s of an inch or 14-15mms would be in the range of 250ccs.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello I am interested in an operation before fall. I just don’t know which one because of my limited knowledge. I would like my side profile to be less “flat” and maybe my nose to be sharper as I think it is flat aswell. My cheekbone and under eye support is also very minimal. Please let me know which procedure I would benefit from so I can do my research before a full consultation.

A:With a flatter midface the discussion is whether infraorbital-malar augmentation would be sufficient or whether it should include the entire midface. (see attached image) Either approach requires a custom implant design to do so.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have several issues. First, I want to define my jaw line .Throughout implant perhaps customized. Second issue is that I had chin implant before and I removed it afterwards. I noticed that the position of my chin changed and as if it was being pulled down. The previous doctor created a kind of pocket to fix the implant, but when I took it out, it pulled my chin down. There was a kind of fall. Can this be fixed?

A:The only way to have a more defined jawline is with a custom implant approach. While you do have thicker tissues, which does make getting more jawline definition harder, your lower face is also vertically short… where jawline lengthening works to help stretch out the tissues.

When chin implants are removed there will be loss of chin pad support, so ptosis is to be expected. A custom jawline implant will fill out that along with improving jawline shape/definition.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am planning to have a sliding genioplasty surgery in order to increase my chin projection 1 cm horizontally. I know that average mandible symphisis thickness is around 1 cm.I have seen some photos from surgeries on internet operated with plates more than 10 mm which puts the lingual cortex of the lower downfractured chin segment in front of the upper fixed chin segments buccal cortex with less than 1-2 mm of horizontal space separating the upper and lower bone segments.İs that kind of advancement stable without the plate ?Can you explain how this two segments fuse? Will only the lingual cortex of the lower segment and buccal cortex of the upper segment fuse and leave the marrow parts exposed? I am very confused.Thank you for answering.

A:Your confusion is understandable as you are only considering the cental part of the chin where the lower segment can be advanced in front of the upper segment. But you are not considering the sides or wings of the advanced lower chin segment which always maintains contact with the upper bony edges. This is what makes the chin segment stable with only central plate and screw fixation. The center part may go on to heal albeit often with incomplete bony consolidation. (harmless but may contribute to deepening of the labiomental fold) Hence the benefits of allogeneic bone grafting of the bony stepoff.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi. I have a very undeveloped mandible and recessed jawline. I had a chin implant surgery more than a year ago and I had no problem with it, but I still don’t get enough projection with it as I desire, especially from the profile. I want my chin to be more forward, but I also want more projection below my chin as well, to look thicker. So this time I would like to do the sliding genioplasty together with customized angular jaw implants. My questions are these:

1) Can a sliding genioplasty be done with the chin implant already in place without taking it out?

2) How much would all these cost?

3) There is currently a gap between my lower lip and chin. The skin there is pulled backward because I never really had a chin. So will that space be pulled forward after the surgery to fill that gap?

I will share the pictures of me before the implant, the current one and the expected one

A: You have correctly surmised that only a sliding genioplasty can provide any further significant horizontal or vertical lengthening.  The movement you have shown is more of a 30 to 45 degree movement (down and forward) which is good to lessen the impact of further chin augmentation on the deepening of the labiomental fold. What you have demonstrated in your chin augmentation goal imaging is exactly what will happen to the fold. (it will get deeper and this is unavoidable) Usually this is grafted with an allogeneic bone block to soften that adverse labiomental fold effect.

It would be ideal to keep the current chin implant in place and do the osteotomy cut above it so it carried forward with the bone movement, keeping the benefits of the prior surgery as well as not making the bone do all the chin augmentation effect. Whether that is possible depends on where the implant is sitting on the bone. Presuming you have a silicone implant in place this will be determined by a 3D CT scan of your face which is needed anyway for the custom jawline implant.

While the sliding genioplasty can make the movement you have desired you said something which is can not do…make the chin thicker. (wider) Thus what you are really looking at doing (need) is to have the jawline implant wrap around the chin to add width. This is needed anyway to cover the bony steps from the sliding genioplasty and well as create a smooth linear jawline effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hi I am seriously considering going to your practice to have mandible implants but am undecided whether to go with conform mandible implants or lateral mandible implants. Can you briefly tell me the differences please. 

My goal is to have jawline accentuation and mainly widening. I have a very narrow face. But I don’t want something too conspicuous or off balance.

A:Pay no attention to the conform concept, thar relates to the internal surface of the implant which has no bearing on its external aesthetic effect.

Jaw angles come down to two different types, widening and vertical lengthening. By your own description the widening style seems appropriate for you. Like most patients your fear of having an implant too big is what being too conspicuous means, thus you want to stay under 10mms prjection for sure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Quick question: on one response from the dr to the question around whether or not silicone testicular implants can be seen on a tsa screen says no , but the same question on another area of this same site says that silicone breast implants and testicular implants can be seen. Which is the correct answer?

A:All medical implants, metallic or not, can be seen on a TSA body scanner. Thus breast and testicle implants can be seen.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Hello, I live in Scotland and I want to have surgery because I am not happy with the shape of my skull. But I have a question, is the back of my skull high or the front low, what do you think is the problem exactly?

A:The interpretation of a head shape is very individualized so either approach (sagittal reduction or forehead augmentation) is an option. Looking at either potential change should help you determine of either skull reshaping approach is an improvement. (see attached imaging) There is no question in just looking at the magnitude of the ‘deformity’ the backward forehead slope/brow bone protrusion is the more significant of the two.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I found your page when searching for testicle enlargement. I’ve been on testosterone for about a year and have noted a significant decrease in the size of both of my testicles during that time.

I have heard of two possible procedures and would like to get information on both.

First is an implant that wraps around the testicle and is filled with silicone.

The second is testicle removal and replacement with an artificial testicle. I realize that this will eliminate my body’s production of T but my level was nearly at the bottom of the scale before I started T replacement therapy. Since I’m doing that already I don’t have any problems with this option.

At this point I’m leaning more toward the second option since the end result is similar and it just seems more reliable over the long term to me.

Just some background information. I’m 67 years old in good health. I have HBP and high cholesterol and take amlodipine, metoprolol tartrate, and simvastatin which control both well.

A:At age 67 there is no question that a solid testicle implant is what you would best suit your situation. The only question is whether testicle removal is really necessary with the placement of the implants. That would be driven by what size testicle implants you desire. In most acses of older men with testicla atrophy the testicles are left in place and larger implants are placed which naturally pushes the testicle out of visibility. (displacement effect) If there is not a big difference between the size of the implant and the testicles then testicle removal would be needed.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q:Dr. Eppley, Is itpossible to contour the body further through liposuction.

In this context, I have a question: Is it possible to define the midline of the abdomen more prominently using liposuction? Or to make the abdomen appear more contoured overall through liposuction?

Please find three reference images attached, including a recent photo of myself.

A:You are specifically referring to abdominal etching, a liposuction technique where lines are placed through linear fat removal. Since you mentioned the ‘midline of the abdomen’ this means midline vertical linear liposuction to make a vertical indentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I have been at a stable weight for years and I don’t smoke.  I lift weights 4 times a week. I had 5 children at 10 to 11 pounds each. I grew up not wearing sunscreen so age, pregnancy, weight loss, and sun damage caused me to have loose skin. I’ve been told I can’t have a BBL because there is not enough fat. 

Would you be able to help me? Not sure if I need a lower buttock lift only or if implants are necessary. I look okay in photos- which is why I sent them- but definitely not in a bikini or naked.  I was excited to find you online because you are exactly whom I was looking for- your skills fit what I’m wanting. 

I look forward to hearing from you.

A:The key to understanding buttock reshaping procedures is what areas they affect. Per the diagram implants affect only the top ½ or 2/3s of the buttocks while lifts/tucks affect only the bottom third of the buttocks.

That being said when you look at your buttocks, while they are a bit flatter in projection,  there is significant ptosis or sag at their lower pole and I would view that as the bigger of the two issues. Thus lower buttock lifts are more indicated for you and you do that first and then see what you thinl about implant augmentation.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Will my surgery leave a scar?

A: The question is not whether surgery will leave a scar, as every incision does, by how significant will that scar be.

There are a wide number of factors that influence the appearance of an incisional scar from how the incision was made, what was done through that incision, the technique of wound closure and the skill of the surgeon doing it, skin type and pigment and where on the body was the incision located.

Scars shold never be considered invisible, just at well levek of inconspicuous will it be.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I’m curious about your thoughts on the correction of low set ears for individuals with disorders like Turner or Noonan syndrome. Attached is not my photo, but a photo of another woman with similar neck/facial structure as myself. I’m aware of otoplasty for things like ear pinning and other ear deformities (my ears are constricted as well as low set), but I have yet to see anything in the literature or otherwise for repositioning ears heightwise. Is such a correction possible? How would you do it, if so? Thanks for your time!

A: The surgery for improvement/correction of low set ears remains currently elusive for me. I have tried numerous techniques all of which have not been successful.  The issue is that the ear is pinned in its loctation by the external auditory canal cartilage. I suspect that the canal cartilage could be transected  and rotated to provide some improved positioning but even that would not provide a major superior relocation of the external ear.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Do you guys offer orthognathic surgery to correct the asymmetry of the jaw or implants? What are the costs of both with the xray that I sent? 

A: The first question is what do you need and what is the best approach for your jaw asymmetry? That would require more information to make that determination. But as a general statement most jaw asymmetries are best treated by a custom jawline implant.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Across the old implant design, CT scan, and picture, are you able to assess whether I have masseter muscle dehiscence? Is it possible that I don’t, and that my current implants poke out without having “broken” the masseter?

If I do have jaw dehiscence, how can that affect the visual outcome of the new implants? (Must I expect repeated implant reveal?)

Does the new implant design need to take any of this into consideration? 

A: The scan is not going to tell you whether you have a soft tissue problem like masseter muscle dehiscence without a special 3D scan that uses soft tissue windows. That is more of a clinical diagnosis, meaning if you bite down where does the bulge of the muscle….over the lower jaw angle or higher up? Having had a combined SSRO with immediate placement of jaw angle implants that is a primary set up for muscle dehiscence.

Implant reveal, or breaking through the muscle, is when the muscle sling is intact but the implant design. square out the angle too much, and the implant is sticking beyond the posterior of the muscle. (like your existing implant design. You have to remember the shape of the follows the shape of the bone. Since all jaw angles are rounder in shape a square jaw angle implant shape can do exactly that.

The current implant design reflects your preference for the shape of the jaw angles not mine. I would not have it so square but have tolerated a shape I am not fond of, due to the risks of muscle dehiscence or implant reveal, because it would probably not being any worse than what exists now because of the encapsulated implant pocket.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley,  i want to ask is any way to elongated medial canthus???im not an Asian i dont have fold i only want to elongate medial canthus.

A: You mean elongate the inner corner of the eye, not the medial canthus.  This is done by a Y-V lengthening procedure.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to get an opinion on what I think should be done my concerns are mainly relating to midfacial hypoplasia – I have a skeletal Class 3. I am thinking if Jaw Surgery would be enough with Custom Implants or if I need a higher Lefort like Lefort 2 – first – I am also concerned about upper maxilla and nose. I am also concerned about the steep mandible that I have which I believe should be slightly corrected in the jaw surgery ( CCW). What do you believe overall is the best approach to my case?

A: I would agree with the concept that any jaw surgery is done first (if indicated) and any bony deficiencies above the LeFort 1 level are dealt with secondarily by custom implant designs. Never try improve bony deficiencies above the maxilla by any type of osteotomy designs. Those LeFort osteotomy designs are made for major skeletal deficiencies, usually of a syndromic origin, not more modest aesthetic deficiencies.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, How much does the occipital surgery cost and when can I return to work?

A: You did not specify what type of occipital surgery….occipital reduction or occipital augmentation….nor what type of work you do. But in either case as a general statement I would say one week.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I am interested in a bridge augmentation only rhinoplasty. it seems like a simple procedure to me but i’ve never seen a surgeon heighten a radix as much as i’d want but that may be more because of patient wishes rather than their inability to do it. i added surgery goal notes as well. one other thing i wanted to add is i want a tapered bridge in a ‘ ) ( ‘ shape (refer to image 2) rather than just a straight rib graft ‘ | | ‘ in image 2 the second photo is an image of my persian friend. people say her nose is way too big but that’s exactly what id want from my rhinoplasty! i feel like we have somewhat similar nose shapes. looking forward to your response 🙂

A: When you put together all of the features of this very specific nose shape (which is not easy to achieve) you are talking an implant approach, specifically a custom nasal implant.  (performed 3D designed siliconje or hand carved ePTFE) While rib grafts are the most common techniques for bridge augmentation the one thing they can’t do is make the bridge wider. (it may even make it thinner) Also no standard nasal implant will achieve it either as they also will not make it wider all the way down to the tip.

I have not seen a side view picture to see what how much height is needed at the radix which is the highest and widest part of his type of bridge augmentation. My preliminary estimate is that it would be at least 7mms.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I would like to schedule a consultation in regards to my nasolabial folds, specifically if I would be a good candidate for excision. I am 30 years old. Thank you.

A: I would never consider nasolabial fold excision at your young age, the scar would never be worth it. You have to consider why they are there…significant facial lipoatrophy. (no subcutaneous fat) You consider augmentation and I don’t mean fat injections which will never work in your face.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, Is the only way to achieve jaw augmentation an incision outer of the mouth area? What about 3 pieces implant? The incision will be visible?

A: Custom jawline implants are placed as one solid piece, which is what you want for their linear effect, through three small incisions. Two inside the mouth back on the cheeks opposite tyhe 2nd/3rd molars and one small one under the chin.

While the intraoral incisions can be replaced by external ones behind the jaw angles that would leave external scars…which for some men may be acceptable but not for females.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Q: Dr. Eppley, I had Medpor jaw angle implants of the lateral style with 9mm width placed 7 months ago, as well as a 7mm forward and 4mm down genioplasty. The left side was placed a little too low, though, and I felt that the genioplasty advancement was too big, so I went to another surgeon to attempt to reposition it and reduce the genioplasty. The genioplasty was reduced successfully, but somehow my left jaw angle was repositioned even lower! You can imagine my horror when I roughly measured that one side was about 1 cm lower than the other!

I am already scheduled to have my jaw implants removed, and it will be 72 days between the revision surgery and the implant removal. I am not so much worried about the right jaw implant, since it only provided lateral augmentation, but I am very worried about sagging from the larger jaw implant. My surgeon said that it will likely sag, but it will be minimal. I have thick skin, and I never had a particularly defined jawline to begin with. What should I expect in terms of soft tissue response. Are there any soft tissue management strategies you would recommend, such as liposuction or fat grafting?

Thank you very much

A: You take out the jaw angle implants first and then see what happens. No one knows how the soft tissue will respond and what, if any, soft tissue problem may ensue. Trust the healing process and don’t get ahead of yourself. Quite frankly these questions are more appropriately directed to the surgeon who is doing the procedure who has full knowledge of your case.

Dr. Barry Eppley

World-Renowned Plastic Surgeon