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Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

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.

September 22nd, 2017

Pocket Location for Hip Implants

 

The newest member of the body implant family is that of hip implants. Augmentation of the lower torso has been done by various styles of buttock implants for decades. While the majority of buttock augmentation today is done by fat injections (aka Brazilian butt lift), there has been a relative neglect of the hips to the side of the buttocks due to either a lack of adequate fat to inject them or poor fat graft take over the often concave and tighter tissues of the  trochanteric hip region.

From an anatomic standpoint, the hip augmentation zone extends from below the superior iliac crest  down over the trochanteric tuberosity of the femur bone. Underneath the skin and fat layers lies the tensor fascia late muscle/fascia (TFL) which attaches to the iliac crest and runs continuous with the iliotibial band (ITB) down to the side of the knee where it attaches to the lateral epicondyle. At its superior extent the TFL combines with the posterior ITB to create the upper half of the hip fascia. Posteriorly this thick fascia connects to the gluteus maximus muscle creating an overall continuous sheet. Underneath the ITB inferiorly is the vastus laterals muscle. The function of the TFL is for hip movement specifically abduction, flexion and internal rotation.

When considering alloplastic hip augmentation one has to decide whether it is to be placed above or below the TFL. This is primarily determined by the size of the implant and the desired dimensions of hip augmentation. Subfascial placement of the implant is more restrictive in size and will have some short term functional issues. (short term side of the knee discomfort due to the ITB attachment It is somewhat analogous to intramuscular buttock implants where the size of the implant is also restricted and it will induce temporary limited range of motion. When the hip augmentation needs are not excessive a subfascial pocket location can be effective and falls into the general implant philosophy that the tissue coverage an implant has the better.

On top of the  fascia or a deep subcutaneous pocket location in hip augmentation offers the opportunity for larger implants both in perimeter surface area of coverage but also in thickness. Having placed numerous such hip implants I have observed that the thickness of the implant is less important than how much surface area it covers. Greater surface area coverage also allows for a smoother transition into the surrounding buttock and thigh contours. Broader hip implants also requires that their softness (durometer) be the lowest possible so they do not feel restrictive in any way.

Hip augmentation can be successfully done using implants. Currently there are no standard sizes or styles of these body implants. Currently I make all such implants are a custom basis based on patient measurements of surface area coverage.

Dr. Barry Eppley

Indianapolis, Indiana

September 18th, 2017

The Mentalis Muscle and Chin Augmentation

 

The mentalis is a well known muscle of the chin. Any chin surgery procedure involves manipulation of this muscle no matter what type of dimensional chin change is being done or how it is being done. (implant vs. osteotomy vs osteotomy) Since it is the only muscle that has attachments to the anterior surface of the chin bone, postoperative problems with its function can occur. While many chin procedures are done successfully with the return of normal muscle function, mentalis muscle dysfunction is not rare and is a frequent source of after surgery chin problems. Given the frequent misunderstanding of the mentalis muscle anatomy and function amongst patients and even some surgeons, its role and relevance in chin augmentation surgery merits review.

The mentalis is a paired central muscle of the chin that runs vertically over the chin bone. It actually has two halves and is separated by a fat pad that is most prominent near its bony origin underneath the labiomental fold below the lower lip. The relevance of this central fat pad in the muscle is not clear. The muscle is attached to the bone at the depth of the internal vestibule superiorly and runs down vertically to insert into the soft tissues of the lower submental chin pad. It is important to appreciate that the point of firm fixation is at its origin to the bone but its insertion is into the soft tissue inferiorly. The primary function of the muscle is contraction of the chin pad superiorly and inward (towards the lower lip) which will concurrently raise the lower lip creating a pout type facial expression. It is innervated by the marginal mandibular branch of the facial nerve which crosses over the jawline laterally to reach the muscle’s surface.

In chin augmentation surgery incisional access is either intraoral through the mucosa or submental through the skin. In sliding genioplasty the only choice is intraoral. But implant placement can be done both ways. Both incisional approaches cut through the mentalis muscle but they do so through different areas of the muscle. (origin or insertion. This is more than just an anatomic distinction, it can have a significant influence on muscle tension and function after surgery.

Cutting through the insertion of the muscle with an intraoral approach does so at the point of its maximal muscle thickness and tension. It is extremely important to leave an adequate cuff of muscle attached to the bone with this maneuver, otherwise there will be nowhere to attach the released inferior bulk of the muscle bellies. Without a reattachment the muscle will contract down, the labiomental fold will get deeper and the chin pad will pull down off of the bone. (chin ptosis)

With a retained muscle cuff onto which the released muscle can be reattached, one is essentially re-establishing muscle length at the thickest part of the muscle. But it is easy to see how the muscle length is changed when the soft tissue chin pad is stretched out by an implant or an advanced bony chin segment. The larger the chin pad displacement the tighter the muscle closure will be. This accounts for many a patient’s complaints of prolonged chin tightness and stiffness after a sliding genioplasty, particularly in large advancements. It can also occur with chin implants and is most commonly seen when the implant rides up high and pressures the resutured muscle origin.

In the submental approach for chin implants, it is the insertion of the muscle that must be cut and lifted up to reach the bone. Since this is not a firm bony attachment, muscle elevation and closure is done at the thinner lower portion of the muscle and has a much lower risk of adversely affecting muscle tension and postoperative function. This is why there are far fewer complaints of chin stiffness and tightness from submentally placed chin implants as re-establishing muscle length is much easier as opposed to pulling the muscle back up to its original bony attachment.

Mentalis muscle anatomy and its function is just one issue to consider in chin augmentation and is most relevant with implants where both incisional options are in play. When the patient prefers an intraoral approach for a standard chin implant I use the muscle splitting approach through its septum rather than cutting the muscle’s bony attachment.

Dr. Barry Eppley

Indianapolis, Indiana

September 17th, 2017

Case Study – Cranial Bone Graft Rhinoplasty

 

Background: Rhinoplasty surgery often entails the need for grafts. Most commonly cartilage grafts from the septum or ear are used as the volume needs are low and it is helpful to have a convenient and anatomically close harvest site. But major nasal reconstruction may need much larger graft volumes for which the rib offers a near limitless amount.

But in some nasal reconstruction cases where other craniofacial work is being performed, the most convenient donor site is one in which it is already open…the skull. Split-thickness cranial bone grafts have a long history of use in facial reconstruction including for reconstruction of the nose.

In reality, cranial bone is not the best graft for use in the nose because it is rigid and has to be made straight by either burring or controlled bending through partial osteotomy cuts.  One must also be careful that it does not put a lot of pressure on the nasal tip skin to prevent soft tissue breakdown. But if careful graft shaping is done, as well as bone fixation if needed, successful outcomes can be obtained with its use.

Case Study: This young female has been involved in a motor vehicle accident and sustained multiple craniofacial fractures of the forehead and midface. While these fractures underwent primary repair she remained with numerous residual brow bone, orbital and nasal deformities.

Under general anesthesia she had her original coronal scalp incision reopened for exposure and cranial grafts harvested to rebuild the frontal sinus and right orbital floor. Medial canthoplasties were also performed from this approach to improve her traumatic telecanthus. Her nasal dorsal had been impacted inward giving her a saddle nose appearance. A long 4 cm cranial bone graft was harvested and reshaped to be straight by partial thickness osteotomies and sutures. The dorsal bone graft was secured by screw fixation at the frontonasal junction. It was combined with a septal columellar strut graft through an open rhinoplasty approach to ensure adequate nasal tip projection.

A satisfactory nasal profile was achieved with good tip projection. The bone grafts has maintained its volume and structural integrity at a there year followup.

Cranial bone is not a primary source for nasal reconstruction grafting due to the limitations of its rigid structure. But if open access to the skull is already present for other procedures, it can make be used successfully.

Highlights:

  1. Cranial bone is one secondary option for dorsal grafting in rhinoplasty.
  2. The curved nature of cranial bone requires graft bending techniques for a straight dorm.
  3. A dorsal bone graft often needs to be combined with a columellar strut for an L-shaped nasal reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

September 17th, 2017

Case Study – Donut Breast Lift with Implants

 

Background: Many breast augmentation patients present with some degree of breast ptosis. When combined with the number of women that are of the belief that an implant can lift up their sagging breasts, it can be a surprise when the concept of a breast lift is discussed as needed with their implants..

While the need for a breast lift is often obvious in some breast augmentation patients (nipple below the inframammary fold), smaller amounts of ptosis present less obvious needs. When the nipple is at the same horizontal level as the fold (grade 1 ptosis), this raises concern as to what may happen to it when a breast implant is placed behind it?

The key to this question lies in the quality of the breast skin and mound tissue. If the skin is tight and the breast mound small, an implant alone will create all the lift that is needed. But if the overlying breast tissues are lax from aging and breast involution, some form of a lift will likely be needed.

Case Study: This 45 year-old female presented for breast implants. But she had first degree ptosis and loose breast skin from age and pregnancies. She did not want vertical breast lift scars.

Under general anesthesia she has saline breast implants placed with a periareiolar or don’t lift performed. Her postoperative result showed enlarged breast, no exaggeration of her preoperative breast ptosis and good areolar scars.

Of the four types of breast lifts, the donut technique is the second on the progression of increasing scar burdens to perform them. By removing an eccentric ring of skin around the areola some skin tightening and a minor amount of mound lifting can be achieved. But because of its limited lifting effect it almost always need to be done in conjunction with implant placement to have the best effect. It is still a ‘minor’ breast lift and should be only used in  cases of first degree ptosis. Prevention of periareolar scar widening is a function of the size of the breast augmentation and the amount of periareolar skin removed.

Highlights:

  1. Breast augmentation in the presence of small amounts of ptosis may benefit from some form of a breast lift.
  2. The periareolar or donut lift is a type 2 breast lift.
  3. The width of the scars from a periareolar lift depends on the size of the size of the breast implants and the amount of skin removed.

Dr. Barry Eppley

Indianapolis, Indiana

September 16th, 2017

Case Study – Osseointegrafted Implant Prosthetic Ear Reconstruction

 

Background: Loss of an ear can occur from a variety of reasons including cancer resection and traumatic avulsion. Such ear amputations pose major reconstructive challenges which can be done using an autogenous method (cartilage framework and vascularized soft tissue cover), completely prosthetic method (ear prosthesis) or a combination of both autogenous tissue and prosthesis. (synthetic ear framework with vascularized soft tissue cover)

While I typically prefer some form of autogenous reconstruction, there is a role for a completely prosthetic ear reconstruction approach. There is no denying that a prosthetic ear created by a Maxillofacial Prosthetist creates the best match to the opposite ear. But the long-term success of an ear prosthesis is directly related to the patient’s comfort in wearing it. If the patient has little confidence that it will stay in place then they are unlikely to use it.

While prosthetic ears were once held in place by adhesives, this is not a reliable method for stabilizing something to the side of the head..Borrowing from dental implant technology, the use of osseointegrated implants has long eclipsed the use of adhesives by providing a bone anchorage method for prosthetic stability.

Case Study: This 35 year-old male had his left ear removed due to melanoma skin cancer. He also had a superficial parotidectomy and sentinel lymph node biopsy. This left him with Frey’s syndrome as well as the absence of his ear. He opted for a completely prosthetic ear reconstruction method.

Under general anesthesia he had a first stage placement of two osseointegrated implants as well as a sheet of Alloderm over the parotidectomy site to treat his Frey’s syndrome. A second procedure was done three months later to uncover his implants and skin graft around them.

A prosthetic ear was created onto which magnetic attachments were placed on its posterior surface. These served as fixation posts onto which the ear prosthesis could attach. This created the bone anchored ear prosthesis.

While a prosthetic ear creates the best looking ear, it will require maintenance on a regular basis. The implant posts must be kept clean so a tight soft tissue collar is maintained. (much like the gums tissues around a tooth) The ear prothesis will need periodic replacements due to color fading and the wear and tear from daily use.

Highlights:

  1. The stability of prosthetic ear reconstruction depends on osseointegrated titanium implants.
  2. Osseointegrated implants need a tight soft tissue collar for long-term retention.
  3. The patient will require multiple prosthetic ears over time due to material aging and discoloration.

Dr. Barry Eppley

Indianapolis, Indiana

September 16th, 2017

The Peaked Shaped Custom Skull Implant

 

Custom skull implants make it possible to effect many different types of aesthetic head shape changes that were not possible just a decade ago. Fabricating the implant from the patient’s 3D CT scan, the only restrictions to its design and size is the limits of how much the scalp can stretch to accommodate it. Placed through relatively small scalp incisions, such custom implants can correct skull asymmetries, help make for a rounder head shape and add volume to flat areas of the skull.

The objective of most aesthetic skull surgeries is to make for a rounder head shape. This is usually assessed in the front view with how it looks across the top the head in its arc from ear to ear. Like facial shapes, head shapes come in heart, square, pear, rectangle, round, oval, diamond and oblong when viewed from the frontal perspective. Most patients would choose the round or oval head shape as the most aesthetically pleasing and this is the form that most skull implants are designed to achieve.

But a few patients may want a non-traditional head shape that does not fall into these classic head shape descriptions. One such example is that of the peaked or sagittal head shape. This is where a raised midline ridge is evident with an overall head shape that is more square. This makes for three distinct angles to the head shape, one in the midline and the one on each side as it transitions into the temporal or side of the head. Some patients replicate this head shape look by their hairstyles. But such head shapes are possible to create by a custom skull implant that is designed to do so.

Such a designed skull implant will show its shape the best in men that have very short cut hair or who shave their head.

Dr. Barry Eppley

Indianapolis, Indiana

September 16th, 2017

The ‘Customizable’ Custom Jawline Implant

 

Bony augmentation of the face has been done by a variety of commonly used facial implants. While many of these implants work fine for standard aesthetic problems of the chin and cheeks, many other facial areas require a customized implant approach. This is particularly relevant when jawline augmentation is needed. Due to the amount of surface area coverage and the thickness and complex shape of the implant, total jawline  augmentation requires the creation of an implant design from a 3D CT scan.

Custom jawline implants are one of the most common types of 3D designed facial implants in my experience. Made from the patient’s 3D CT scan, its design can be planned employing chin and jaw angle measurements and how to make the connection between them. While the implant can be designed to any specifications, the question always is what should those exact dimensions be? The answer to that question for each patient is not precisely known. There is no software program that can tell us how to make the implant for the exact type of facial change the patient seeks. This remains the art form of any custom facial implant design.

As a result there are certainly circumstances where both the patient and the surgeon may question whether the final design chosen and the manufactured implant will best serve their aesthetic needs. Such questioning may exist right before surgery (on the part of the patient) or during surgery. (on the part of the surgeon) The good news is that any custom implant, even larger jawline implants, can be changed or modified during surgery. Using large scalpel blades and experience in doing it, the custom implant can be reduced in size and its shape modified prior to placement.

This customizable custom jawline implant approach allows for shape changes that either have become apparent during surgery or for modifications that the patient desires right before surgery. Such changes do not violate the integrity of the implant or makes it lifelong durability any less.

Dr. Barry Eppley

Indianapolis, Indiana

September 15th, 2017

Case Study – Facial Reshaping Surgery with Chin Augmentation and Facial Fat Removal

 

Background: The round face is often characterized by soft tissues excesses and bony deficiencies. It takes a combination of both tissue issues to create a round or convex facial shape. Very often the lower jaw/chin is short or deficient and the lack of a bony projection is the linchpin to this type of facial shape. While such a facial shape may be adorable as an infant or young child, it is often not perceived so in adulthood.

When the chin is short, the debate is often between that of an implant or a sliding genioplasty. There are advantages and disadvantages to either chin augmentation method. But the round or fuller face usually has a fuller submental fad pad and attached neck muscles that are relatively short. Moving the chin forward in the round face has the advantage of stretching out the attached neck muscles and improving the shape of the neck even if liposuction or a submentoplasty are still going to be performed.

The other component of the round face is excessive fat. While removing facial fat alone rarely changes one’s facial shape entirely, it still has a valuable role in facial reshaping surgery. Facial fat removal maximally consists of addressing the three main compartments of the buccal space, perioral mound/jowls and that in the neck..

Case Study: This young female had a very round face and short chin. She had an orthodontically corrected Class II occlusal relationship.

Under general anesthesia she had a 10mm sliding genioplasty advancement combined with buccal lipectomies, perioral and neck liposuction for an overall facial reshaping effort.

Her after surgery results showed a dramatic change in her facial shape with a better defined chin and jawline and much thinner looking face.

The combination of bony augmentation and fat reduction can produce a diametric facial effect which leads to a significant change in one’s facial shape.

Highlights:

  1. Significant facial reshaping often requires a combination of bony augmentation and fat reduction.
  2. A sliding geniopslasty helps the fuller neck by stretching out attached neck muscles.
  3. The combination of buccal lipectomies and personal and neck liposuction are the most fat reduction that can be done in the round face.

Dr. Barry Eppley

Indianapolis, Indiana

September 11th, 2017

Case Study – Teen Sliding Genioplasty and Step-Off Grafting

 

Background: The sliding genioplasty is a well known autogenous chin augmentation procedure. When contrasted to that of a chin implant, it has advantages and disadvantages to the alloplastic alternative. Which chin augmentation approach is best for any patient must be decided on an individual basis. Suffice it to say two different chin augmentation techniques exist since neither one is perfect for every patient’s aesthetic chin needs.

One feature of any horizontal chin augmentation procedure is that the depth of the labiomental fold will not be improved and may even get deeper. This is expected as the attachment of the mentalis muscle to the bone, which is the anatomic basis for the presence of the fold, does not change. The down fractured chin segment from a sliding genioplasty is done below the level of the muscle attachment. (even though the muscle must be cut and then reattached to perform the procedure) Thus as the chin comes forward the labiomental fold attachment remains the same. By definition this can make the labiodental fold look perceptibly deeper. Whether his usually negative aesthetic effect will be significant depends on how much chin advancement is done.

In lowering the risk of labiomental fold deepening with a sliding genioplasty, the bone step-off can be filled in with a variety of materials. This is particularly relevant when the chin advancement becomes considerable. There are a variety of alloplastic and allogeneic materials from which to choose.

Case Study: This 15 year-old male had a short chin although an orthodontically corrected Class I occlusion. Given his young age and the degree of horizontal chin advancement needed, a sliding genioplasty procedure was chosen.

Under general anesthesia and through an intraoral approach, a low horizontal bone cut was done and the chin bone advanced 12mms. The bony step-off was filled in with hydroxyapatite bone cement with the mentalis muscle closed over it.

His after surgery result showed an improved lower facial profile with increased chin projection. The depth of the labiomental fold was deeper but not unduly so. It would have been deeper without the fill in with the bone cement.

Hydroxyapatite bone cement is one option for augmenting the underlying bony step-off in a sliding genioplasty. Its only limiting factor is its cost.

Highlights:

  1. The sliding genioplasty moves the bottom portion of the chin bone forward but leaves the superior portion of the bone and the labiomentall fold behind.
  2. The bony step off of the sliding genioplasty can be augmented or filled in with a variety of materials.
  3. Grafting the step off in the advanced chin can help soften any deepening of the labiodental fold.

Dr. Barry Eppley

Indianapolis, Indiana

September 11th, 2017

Case Study – Silicone Testicle Implant Replacement

 

Background: Testicle implants are available in saline filled and solid silicone types. The solid type of implant would generally be considered superior as it can never fail or deflate over the patient’s lifetime. But despite this advantage, it still has to be the right implant size, shape and feel for an optimal aesthetiuc outcome. In addition the pocket and location of the implant should be as close as possible to the opposite side. (even though natural testicles do not hang symmetrically)

While silicone implants do exist for testicle implants, they are not all the same and are produced by different manufacturers. Beyond the size limitations of some scrotal implants, the softness of them is also a very important feature. The lowest possible durometer or silicone elastomer cross-linking should be done to ensure they have the greatest compressibility while still being a cohesive structure.

Case Study: This 50 year-old male had a history of testicular cancer with a solid silicone implant placed after testicle removal and radiation therapy. While the implant was clearly better than no replacement at all, its size was inadequate. Also its smaller size and higher position inside the scrotum allowed it to fall back between the legs…an uncomfortable and annoying issue that constantly required repositioning.

Under general anesthesia, a midline scrotal incision was used as a scar was already in this location. The existing implant was removed and a capsulotomy performed to lower the implant pocket in the scrotum A permanent implant stores was also removed from the prior surgery. The new implant replacement’s size and shape could be seen compared to the removed implant. The softness of the new implant could be seen to be greater than the previous implant.

His immediate result at the end of the operation could be seen to have improved scrotal symmetry. It is presumed that the larger implant with a lower pocket will prevent posterior migration between the legs when erect.

Highlights:

  1. The best silicone testicle implant is one that has adequate size, shape and a very soft feel.
  2. Malpositioning of a testicle implant requires a capsulotomy and pocket adjustment.
  3. A midline scrotal incision is the best approach for repositioning the implant pocket.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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