Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?
Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.
October 26th, 2016
Skull augmentation is an essential procedure in aesthetic skull reshaping surgery. While onlay cranioplasty (aka skull augmentation) can be done by using a variety of synthetic materials, larger expansions of the skull’s outer surface are most reliably done using 3D custom implant designs. Using the patient’s 3D CT scan, a custom skull implant can be designed to cover a large surface area of the skull. When placed over the patient’s head prior to insertion it can be seen to be impressive in size.
The implant is placed through a scalp incision as small as possible. Even such a large skull implant can be placed through an incision smaller than its width due to the implant’s flexibility.
How large a skull augmentation that can be accomplished is determined by the ability of the scalp to stretch. After the incision and undermining the scalp can stretch to cover an implant to varying degrees. Each person’s scalp has different amounts of elasticities which is partially related to how thick it is. The thicker the scalp the more it is capable of stretching in my experience. There is an unknown balance in each patient between how much their scalp can stretch vs how large can the skull implant be. This is carefully evaluated and thought through during the custom skull implant design process.
When it is believed that the amount of skull augmentation desired exceeds the ability of the scalp to stretch to accommodate it, a first stage scalp tissue expansion is needed. A small inflatable device is initially placed and expanded by percutaneous saline injections until the scalp has developed additional stretch. This is usually done six to eight weeks prior to the placement of the custom skull implant. This is needed in less than 10% of skull augmentations in my experience.
Dr. Barry Eppley
October 25th, 2016
Lipomas are the most benign soft tissue tumor. They are easy to identify by examination as they are circular, slightly mobile and are located right under the skin. Almost no matter what size they grow to they are generally painless. The vast majority of lipomas are fairly small and 1 cm or less in size. They usually occur as a single soft tissue mass in adults.
But there are many different types of lipomas as they are not just one single type. Certain types of lipomas are congenital, grow to bigger sizes and are not just restricted to the subcutaneous tissues. They can be partially located in the muscle and be more ‘invasive’. They continue to grow over time and cause discomfort by putting pressure on the surrounding tissues.
This is an example of a congenital intramuscular lipoma that was removed off of the scapula (shoulder blade) on the back. While part of it was right under the skin, a larger part of it had to be removed from the muscle right down to the surface of the scapular bone. Despite its large size it can be removed through a relatively small incision for minimal scarring..
Dr. Barry Eppley
October 24th, 2016
One of the most common features of the aging process is sagging of the neck. When more advanced the central neck become a repository for loose skin, fat and and the appearance of platysmal banding. While platysmal banding is part of every aging neck, it is usually only seen well in thinner necks with less subcutaneous fat.
Most necklift techniques involve some form of platysmal plication. This is where the split medial edges of the platysmal muscle are sewn together usually after some defatting as well. There have been numerous platysmal suture techniques described but at the core of them all is that is a platysmal tightening method.
In the October 2016 issue of the journal Plastic and Recostructive Surgery an article was published entitled ‘Complete Platysmal Transection in Neck Rejuvenation : A Critical Appraisal’. The authors used a necklift technique of full skin undermining complete platysmal transection and midline platysmal approximation. In 150 consecutive necklift patients operated on over a four year period, results were compared at 3 and 12 months to determine persistence of anterior neck tightness. Patient satisfaction was 100% at three moths which fell to 76% at one year after surgery. Physician assessment, however, showed that only 50% had no anterior neck skin excess and 55% had no recurrence of platysmal bands at the one year assessment period.
There were no major complications with this necklift technique such as nerve damage, large hematomas or skin necrosis. The biggest drawback was the prolonged edema (swelling) that persisted in the neck often out to two months after surgery. Two-thirds (67%) of the patients reported having a ‘hard neck’ for a long time.
Overall this necklift technique has a high patient satisfaction rate even out at one year after surgery. An interesting question about platysmal bands is why they recur after being cut. The authors propose that it could be de to either inadequate muscle resection, muscle regeneration or restoration of motor nerve function. Regardless of the mechanism complete transection of the muscle does not permanently eliminate the development of platysmal bands. This study provides clinical evidence that it does not.
What this study shows is, to some degree what all plastic surgeons know, a necklift procedure is not permanent and begins ‘going downhill’ as early as 3 to 6 months after surgery. There is an expected amount of recurrent anterior skin laxity and platysmal bands by one year after surgery despite an aggressive neck contouring technique. Such information is valuable preoperative education information.
Dr. Barry Eppley
October 24th, 2016
The decision to undergo surgery with a custom facial implant for aesthetic facial augmentation is an exciting change. Like all elective surgeries, there is a recovery process before the patient will finally see the results of the implant design and surgical placement efforts. This is a predictable process that always involves more swelling than expected and a recovery period that is longer than one wants. In understanding the recovery process, here are five key points to know before surgery.
Most custom facial implants cause a great deal of swelling.What is unique about most custom facial implants is that they are usually larger in size and, as a result, involve more tissue dissection to be placed. While the entry incision(s) may be small, the internal area dissected is much larger. This usually creates a significant amount of tissue swelling and facial distortion. It is almost always much more than any patient can anticipate. No matter how much you think it can swell and cause the image you see in the mirror to become almost unrecognizable, it will likely be even more so.
The swelling phase is both predictable and prolonged. Facial swelling after implant placement follows a predictable postoperative course. It will take at least two days for the peak of the swelling to occur. While you may feel as though you might not look too badly the day after surgery… more swelling is yet to come. Once the swelling has peaked, it will go down on a decreasing percent resolution over the next six to eight weeks. At ten days, 50% of the swelling will be gone, two-thirds to 75% by three weeks and about 90% by six weeks after surgery. This postoperative course indicates that it will take several months following surgery to truly see the final results of your custom facial implant procedure. Any judgment beforehand would be premature.
The recovery process can be very stressful. While the swelling and the course of its resolution is explained in detail before surgery, managing it can be very different from understanding it. Many patients go through a difficult and psychologically distressing period after surgery. Viewing your own face while it is distorted during recovery is very challenging versus what is revealed during the implant design process in the 3-D planning pictures prior to surgery. This can make some patients concerned that something has gone wrong or they have chosen an incorrect the implant design(s). It is very important to expect this period of adjustment and stress to happen after surgery, and to understand that recovery is a process. What you see in the mirror just days or weeks after surgery is not the final result.
Evaluating the final results from custom facial implant surgery takes time. Because facial recovery can be very psychologically disturbing, some patients think about changing the implant design or even removing implants in the first month after surgery. Such decisions are completely premature and are emotionally based rather than logical. It is important that one persist through the full extent of the recovery process until the final results of surgery are visible three to six months following the procedure.
Custom facial implant results are as much an art form as a science. While the use of 3D CT scans and computer software to design these implants appears very scientific and exacting, it is only partially so. No one can predict with great accuracy how any implant design will look on you. How the soft tissues will drape over the implant and appear on the outside remains an unknown variable in every patient’s surgical outcome. While serious medical issues from this type of facial surgery are rare (e.g., infection), aesthetic adjustments to the implants are not. But before any such secondary surgery should be considered necessary one should wait until the full recovery process is complete.
Dr. Barry Eppley
October 22nd, 2016
Breast lifting is often needed in breast augmentation surgery when the nipples sits at or below the level of the inframammary fold. While there are four different types of breast lifts, the most effective of them involve the excision and tightening of skin beyond the areola on the lower pole of the breast.
Breast lifts create unavoidable scars that traverse vertically down the lower pole of the breasts and often along the inframammary fold as well. While not as visible as a scar that is on the upper pole of the breast, such healing scars are disconcerting to most women nonetheless.
Like all scars, breast lift scars undergo an evolution in their healing process. While many breast lift scars go own to look very acceptable, it is a long process of scar maturation to get there. Initially after surgery the scar lines from a breast lift look very fine with good skin color. This is because in the first few weeks after surgery there is a minimal inflammatory response along the incision lines. This fools patents because they mistakenly believe that this is the worst they will look and time will make them even better.
But the very early appearance of breast lift incisions belies what is forthcoming. As the inflammatory response ensues and true healing of the incisions begins they will turn red due to the ingrowth of blood vessels. The scars will continue to turn red and will remain so for several months as the healing process continues. Once the incisions are fully healed only then will the color of them begin to fade. This scar maturation process can take six to nine months, and sometimes longer, to appreciate what the final appearance of the breast lift scars will be.
While breast lifts are always a ‘necessary’ aesthetic surgery in breast reshaping, they create their own adverse tradeoffs. While implants create an immediate and gratifying effect, the scars of breast lifts take longer to reach a satisfying conclusion
Dr. Barry Eppley
October 22nd, 2016
Significant aging of the neck is most commonly treated by a neck lift, also known as a lower facelift. While earlier signs of neck sagging/fullness may be treated by liposuction and other more limited procedures, true neck wattles can only be treated by more traditional and aggressive approaches.
A lower facelift/necklift repositions the hanging neck skin back towards the ear and removes the excess tissue there. This requires incisions to be placed around the ears. Thus the tissue removed results in scars that are placed in relatively inconspicuous locations. This is a fundamental principle of facelift surgery. But men pose unique challenges in facelift surgery because of their often limited hair or short hairstyles around the ears. This makes it hard to hide the facelift scars and, as a result, may also make it difficult to get a good neck lift result.
An alternative technique in older men that have significant neck wattles is the direct neck lift. As the name implies the neck wattle is cut out directly down the center of the neck. The key to doing this surgery with the best scar result is how the pattern of skin and fat is removed. It is not just an elliptical excision of tissue down the center of the neck. If it were there would be dogears (redundant skin) at the top and bottom of the need of the elliptical excision. Rather the skin cutout pattern resembles the shape of a candelabra or urn. This places a smaller horizontal skin excision in the submental area and a larger horizontal skin excision at a lower neck level. This creates an I-shaped closure line in the neck.
The direct necklift is a tremendously powerful procedure for removing neck wattles. It is actually more effective than a traditional fuller neck lift/lower facelift because it removes the neck wattle directly. But it does so at the expense of neck scars and that is its major consideration. Fortunately the beard skin in older men (greater than age 65) heals very well. At this age the direct necklift offers a less invasive procedure with minimal recovery and avoids scars and potential hairline disruption around the ears.
Dr. Barry Eppley
October 22nd, 2016
The development of new jaw angle implant styles has finally allowed augmentation of the back part of the jaw to get caught up with that of the chin. The jaw angles have been overlooked for a long time as implant styles and sizes of the chin have progressed. With the chin and jaw angle implant styles that are now available the entire jawline can be augmented in the properly selected patient.
With newer jaw angle implant styles, it is important that the indications for their use are clear. Traditionally jaw angle implants really only provided width to the mandibular ramus. They were designed to sit on the bone on its natural shape, thus increasing its lateral projection. Making the jaw wider is an effective aesthetic strategy provided the mandibular plane angle is not too high. If the jaw angles are within 2 cms or lesss from the earlobe they would be considered high jaw angles. A high jaw angle that is made wider can potentially make the face look too full or chunky and not create a more defined and stronger jawline.
This is a 3D CT example of this exact mismatched jaw angle implant problem. This patient has very high jaw angles and a steep mandibular plane angle. While these widening jaw angle implants are reasonably well placed over the rami the patient developed an undesired facial appearance as the enhanced jaw angles remained too high.
Newer styles of jaw angles help vertically lengthen the lower border of the mandibular ramus to treat the high jaw angle patient. This is a very unique facial implant style as a portion of the implant sits off of the bone to create its effect. As much as one third of the implant does not sit on the bone. In lowering the jaw angle it becomes more visually defined and the lower face appears more filled out in the front view. Vertical lengthening of the jaw angle is the most assured way to create a more visible back part of the jaw as it effectively corrects a bone ‘deficiency’. (missing part of the jaw) However one must be careful to not over lengthen the mandibular ramus as it can also make the lower face look too heavy in the patient who has a normal mandibular plane angle.
This is a 3D Ct example of jaw angle implants that provide vertical lengthening. A portion of the implant design is off the bone to both lower and make more prominent the jaw angle shape at the back of the jaw. This is the appropriate jaw angle implant style for the high jaw angle patient.
Jaw angle implants today come in both widening and vertically lengthening styles. Each style does add some of the opposite dimension as well. Widening angle implants can add a little vertical length based on how they are positioned. Conversely the design of the vertical lengthening implant has built in width that increases the more it lowers the jaw angle
Like all facial implants not every standard shape and size works well for every patient. Significant jawline asymmetry, postoperative orthognathic surgery bony changes of the ramus and aesthetic dimensoonal needs beyond standard sizes are all reasons to consider custom jaw angle implant designs.
Dr. Barry Eppley
October 20th, 2016
Orthognathic surgery is a well known type of bone procedures that move the upper and lower jaws to improve one’s bite (occlusion) as well as improve jaw relationships to the face. It is done on the upper and lower jaws with the mainstay procedures of a LeFort I osteotomy (upper jaw) and sagittal split ramus osteotomies. (lower jaw)
The LeFort I osteotomy moves the upper jaw and is done by a horizontal bone cut above the level of the upper tooth roots across the maxilla and nose. This allows the entire dentoalveolar unit of the maxilla to be moved horizontally forward or vertically up or down. When seen intraoperatively it is a dramatic procedure when one sees the whole upper jaw brought down to peer into the maxillary sinuses and the nose.
A much less known maxillary bone procedure is that of the premaxillary osteotomy. As the name suggests it is just a part, the front part to be specific, of a LeFort I osteotomy. This is the anterior maxillary segment that contains the six front teeth from canine to canine. It is unique from the Lefort I osteotomy because it requires a vertical bone cut between the canine and premolar teeth as well as a bone cut across the palate to get the bone segment to move.
The indications for a premaxillary osteotomy are very limited. The picture in this blog is from an older patient who wanted his front upper teeth moved up and back to correct a lifelong tongue thrusting problem. This was able to be done for him because he was already missing his first premolar tooth on the right side and had a decayed second premolar tooth on the opposite side which could be removed. This provide a safe space to make the vertical bone cuts.
October 19th, 2016
Chin augmentation is traditionally thought as a choice between a chin implant and a sliding genioplasty. While seen as the two procedure choices for chin reshaping they are not really interchangeable. Besides the difference between synthetically augmenting the bone vs actually cutting and moving the bone, they can achieve different dimensional chin changes.
The one movement that a sliding or bony genioplasty can do much better than an implant is changing the vertical dimension of the chin. While it is obvious that an implant can not shorten the chin, it historically could not lengthen it very well either. That has changed more recently with vertical lengthening chin implant styles. But the intraoral genioplasty remains an historic mainstay for increasing the vertical length of the lower face. (chin)
Done through an intraoral mucosal incision, the chin bone is cut well below the level of the lower tooth roots. An opening wedge is performed by dropping down the chin bone to the desired vertical distance that is needed to create the aesthetic result. In most cases the vertical gap that needs to be created is at least 7mms. Much less does not produce a very obvious vertical lengthening. The amount the vertical gap can be opened is only limited by the length of the fixation plate used and what other chin dimensions need to be changed if any.
A debatable issue with vertical chin lengthening is whether the bone ago created between the two chin segments needs to be filled in. In small gaps in the range of 5mms or less grafting of the defect is probably not needed. The body will fill it in on its own. But larger bone gaps should be grafted. I prefer to use allogeneic cadaveric bone grafts which conveniently come in wedge forms that can fit nicely as an interpositional bone graft.
October 19th, 2016
Background: Breast implants are intended to enlarge the existing breast mounds. In so doing it is often erroneously believed that other features of the breast may be similarly improved. Unfortunately this is rarely true. Conversely any other deformities or asymmetries of the breast may actually become more noticeable not less.
The most visible feature of the breast mound is the nipple-areolar complex. It has features from size (diameter), nipple projection, to its position on the breast mound. Enlarging the breast will increase the diameter of the areola. Implants will not change nipple projection unless nerve sensation is lost. Uneven horizontal nipple positions between the breast mounds will be greater as the breast gets bigger.
One unique dysmorphic feature of the nipple-areolar complex is that of the ‘puffy nipple’. This is where the entire areola puffs outward due to a collection of breast tissue beneath it. This almost always occurs as part of the spectrum of tuberous breast deformities. In its most minor form, a constricting ring around the base of the areola creates a small herniation of breast tissue through the areola ring creating a puffy nipple appearance.
Case Study: This 22 year-old female presented for breast augmentation due to her natural flat chest. What she did have were larger areolas that stood out due to their puffiness. The areolas were soft and could easily be pushed in. Her understandable question was whether breast implants would push out the breast mound behind them and make them less puffy.
Under general anesthesia, she had 400cc high profile smooth silicone breast implants placed in the dual plane position through inframammary incisions. Her immediate and early postoperative results showed no change in the appearance of her areolar protrusions.
Longer term followup failed to show any improvement in her puffy nipple concerns. This proves that the push of an implant behind an areolar protrusion does not improve it. This makes sense since anatomically a ‘hernia’ can not be reduced by pushing on the side that the prolapsed tissue emanates.
The puffy nipple must be treated by excision of breast tissue through a partial areolar incision. This can be done at the same time as the breast augmentation or deferred until the patient is convinced breast implants alone are not corrective.
1) Breast implants are well known to magnify the existing features of the breast.
2) The features of a nipple are not changed/improved because the underlying breast volume is enhanced.
3) The puffy nipple or the microform tuberous breast is NOT flattened because a breast implant is placed behind it.
Dr. Barry Eppley