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Dr. Barry Eppley

Explore the worlds of cosmetic
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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.

February 26th, 2017

Inferior Border Jaw Shave in Facial Asymmetry

 

Facial asymmetry is not all that uncommon and can occur for a variety of reasons and in different degrees of expression. But the most common reason for facial asymmetry is developmental that becomes apparent as facial growth completes by late teenage years. In the majority of developmental facial asymmetry cases, the abnormal side is positioned lower. It is very rare to have the normal side be the ‘low’ side and the abnormal side be the ‘high’ side.

One of the most conspicuous features of many facial asymmetry cases is the lower jawline. The affected jawline hangs lower and is obviously different than the other side since it is an edge or profile facial feature. X-rays will show that the jawline is usually vertically longer and even the intraosseous inferior alveolar nerve canal and tooth root positions are lower than the other side. This may be associated with a cant to the occlusal plane.

x-ray for Inferior Border Jawline Shave Dr Barry Eppley IndianapolisCorrecting the ‘hanging’ lower jawline is often one of the important procedures that are needed for improved facial symmetry. The simplest and very accurate way to determine how much of the lower end of the jawline that needs to be removed is to take measurements on a panorex x-ray. This tomoraphic films lays out the 3D image of the lower jaw in a 2D fashion.Tracings will show how much lower the affected side is and where the nerve lies so a safe ostectomy line can be made.

The best and most accurate method to perform an inferior border reduction of the lower jaw (inferior jawline shave) is from a submental approach. While many patients would prefer an intraoral approach, this makes it very difficult (if not impossible) to make an accurate line of reduction and also places the mental nerve at risk of injury. While the submental incision creates a small fine line scar, it offers a bone cut that can be made with a direct line of sight back to the jaw angle.

Inferior Border Ja Shave bone specimen Dr Barry Eppley indianapolisThe submental incision best protects the inferior alveolar nerve in the bone as well as the external mental nerve exit into the soft tissues. With a long saw blade on a sagittal saw the desired amount of inferior border bone can be removed in two or three pieces that best matches what has been presurgically outlined on the x-ray.

Dr. Barry Eppley

Indianapolis, Indiana

February 26th, 2017

Technical Strategies – Pennant Corner of Mouth Lift

 

The lips play a major role in the appearance of the lower third of the face. Their size and shape gives indications of gender, expression and age. The lips are well known to be affected by age with thinning of the amount of vermilion show, lip lines and downturning of the corners of the mouth. The inversion of the smile line is caused by the overall southern slide of the facial tissues from the cheeks down to the jawline. This pushes the sides of the mouth downward while the central portion of the lips remains stable.

The correction of downturned mouth corners to a more horizontal position is done by a corner of mouth lift procedure. This is a rather old anti-aging mouth procedure that employs a wedge of skin excision just above the downturned mouth corner. In a triangular or heart-shaped pattern, the removed skin allows a place for the depressed  mouth corner to be elevated and inset. While effective it leaves an incision line on the skin that trails away from the mouth corner in the direction of the ear.

Pennant Corner of the Mouth Lift Dr Barry Eppley IndianapolisI have never liked this resultant skin scar from the traditional corner of mouth lift. As a result I have devised a new variation of this operation that eliminates this skin scar. The excision pattern is done using a ‘pennant’ skin excision/incision line pattern. The skin above the mouth corner is removed in a triangular pattern but there is an incision line that goes down along the lower lip vermilion-cutaneous junction. This allows the corner of the mouth to be excised and the mucosal mobilized. A wedge of orbicularis muscle is also removed and sutured upward to create a deeper corner of the mouth elevation. The corner of the mouth is then elevated and inset into the skin removal site.

Corner of Mouth Lift result front viewCorner of Mouth Lift result Indianapolis Dr Barry EppleyThis mouth corner mucosal transposition flap effectively raises the mouth corner but keeps all the incision lines at the vermilion-cutaneous junctions. It does lengthen the horizontal smile line a few millimeters per side but this is often an aesthetic benefit. If one so desires the mouth corner can be elevated even higher above the traditional horizontal level into a more upward turn. (lip curls)

Dr. Barry Eppley

Indianapolis, Indiana

February 22nd, 2017

Lip Augmentation and Lip Aesthetics

 

Lip Augmentation Dr Barry Eppley IndianpolisThe shape and size of the lips, particularly in females, is an important feature of the lower third of the face. This is very apparent when one looks at the tremendous popularity aesthetic lip augmentation, primarily done by injectable fillers, has enjoyed over the past two decades. Despite their popularity and the tens of milions of lip augmentation procedures that have been done, the end goal of increased lip size has always been based on patient and/or surgeon preference.

In the February 2017 Online First edition of the JAMA Facial Plastic Surgery Journal, an article was published entitled ‘A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness’. This was a clinical study to evaluate what lip dimensions are the most attractive in Caucasian females. Using synthetic morphed frontal digital images of the faces of twenty young women five varied lip surface areas for each face were created.  (amounts of lip augmentation) Those one hundred faces were then assessed for attractiveness. (phase 1) Additional image evaluations were done manipulating upper to lower lip ratios while maintaining the most attractive surface area from phase 1. (phase 2) Lastly the surface area from the most attractive faces was used to determine the total lip surface area relative to the lower facial third.

Their results showed that an increase of just over 50% in the total lip surface area with a linear dimension equal to roughly 10% of the lower face and an upper to lower lip ratio of 1:2 was found to be the most attractive.

While lip dimensions and ratios derived in this study provide some guidelines for lip augmentation efforts, in the end the only aesthetic criteria that matters is in how the patient perceives their own lip size and shape. Probably more important than size is lip symmetry and a well-defined vermillion-cutaneous junction particularly across the cupid’s bow region of the upper lip.

Dr. Barry Eppley

Indianapolis, Indiana

February 22nd, 2017

Bicep Implants – Five Things to Know

 

Muscle enhancement of the body with implants has a far shorter surgical history than that of facial augmentation. Pectoral and calf implants are the most recognizable body implants to enhance muscular size and definition in men. But other body muscles can be synthetically augmented but because they are done in such few numbers, the public is largely unaware of them.

One type of body implant for upper extremity augmentation is that of bicep implants. Bicep implants are used for a variety of upper arm concerns such as aesthetic muscle enhancement or in the correction of congenital deformities such as Poland’s syndrome caused by underdevelopment or from muscle atrophy effects due to a bicep muscle tear or surgery. They have a very successful history of favorable patient outcomes with a low risk of complications. Here are five of the most important concepts to know about bicep implant surgery.

A Bicep Implant Is Not The Same As A Breast Implant. A breast implant is a two part medical device that has an outer silicone shell (bag) which contains either saline or a silicone gel. They have a limited span and will not last forever in any patient. One day the bag will develop a tear and the failed implant will need replaced. Conversely, bicep implants are made of a solid but very soft silicone material that can not fail, rupture or break apart. They are permanent medical devices from the perspective that they will never need to be replaced due to loss of implant integrity.

Bicep Implants Incision Markings Dr Barry Eppley IndianapolisA Bicep Implant Is A Muscle Implant. What is unique about most body implants is that they are designed to make the natural muscle bigger and are thus ‘muscle implants.’ They are usually shaped like the muscle they are designed to enhance. Although they are solid implants they are very soft and flexible and will essentially feel similar to the muscle they are designed to enhance. They are made of a very spongy solid silicone material which allows for tremendous flexibility without tearing or fracturing the implant.

Bicep Implants Are Not Just For Body Builders. Many people have the misconception that a man gets bicep implants because they want to look like a body builder. While that may be true in some cases, it is actually not the most common reason. They are far more frequently used in men who can not adequately develop sufficient upper arm size through exercise or who have arm deficiences/asymmetries due to a congenital or developmental anomaly. In other words they are used for men who are seeking to look more normal and fit but not necessarily ‘supernormal’.

Custom vs Standard Bicep Implants Dr Barry Eppley IndianapolisBicep Implants Come In Standard or Custom Made Sizes, Since the shape and size of male arms are different, it is no surprise that bicep implants are not just ‘one size fits all’. The shape of a bicep implant is more cylindrical (technically half of cylinder in length) whose length is critical. They should be no longer in length than the length of the muscle bulge when the arm is flexed at 90 degrees. Three standard size bicep implants exist as well as they can be custom made for each patient based on preoperative measurements

Right Bicep Implant result intraop Dr Barry Eppley IndianapolisBicep Implants Are Placed Through High Axillary Incisions. As part of a successful bicep implant surgery, the incision to place the implant should be hidden. The best place to insert a pectoral implant is through an incision way up inside the armpit. Others have advocated a mid-incision so the implant could be placed beneath the biceps muscle, this risks motor nerve injury. A subfascial implant location (on top of the muscle) works well in my experience. Incisions in the armpit usually heal very well and are hidden up under the lateral border of the pectoral muscle.

Dr. Barry Eppley

Indianapolis, Indiana

February 22nd, 2017

Case Study – V-Line Jaw Reduction Reversal

 

Background: One of the most popular jawline surgeries around the world, particularly in Asian people, is jaw reduction. Know more commonly as V-Line jaw reduction surgery, it involves removal of wide or flared jaw angle (amputation) and chin reshaping. (narrow and shortening through am intraoral T-shaped ostectomy) For those patients that have a wide jaw and and a lower facial prominence as a result, it can be an effective lower facial reshaping procedure. It is easy to see why this would be of aesthetic predominantly in Asian patients given their natural facial bone shape.

Because the procedure is performed exclusively through an intraoral approach, it can be very difficult to have even and symmetric bone cut lines. There is also the issue of how the bone heals and the smoothness that may or may not result. For this reason, it is really the norm to expect some bone asymmetries between the two sides of the jaw and even at the chin. Fortunately the overlying soft tissues are thick and can help mask such bony asymmetries/irregularities should they result from the procedure.

But like reduction surgery anywhere on the face and body, losing bone support can also cause adverse soft tissue issues. This is an issue primarily in the jaw angle areas in V-line jaw reduction surgery. It is not rare that I hear from a patient who has had jawline reduction surgery that they do not like the subsequent flattening/weakness of the back of their jaw and that they feel the soft tissues now sag along the jawline.

Jawline Deformity after Jaw Angle AmputationJawline Deformity after Jaw Angle Reduction fronkt viewCase Study: This 45 year-old Caucasian female had V-line jaw reduction surgery three years previously. She did not like the subsequent loss of her jaw angles, lack of jawline definition and how it made her lower face too narrow and more aged in appearance. She wanted more defined jaw angles vertically and a smoother and more linear jawline coming forward. A 3D CT scan shows the loss of jaw angles, higher positioned jaw angles, severely increased mandibular plane angle and inferior border jawline asymmetry.

Custom Jawline Implant foir Jawline Reconstruction after Jawline Reduction side view Dr Barry Eppley IndianapolisCustom Jawline Implanty after Jawline Reduction Surgery design front view Dr Barry Eppley IndianapolisA custom jawline implant was designed with the main purpose of re-establishing the jaw angles in a much lower position but without adding any significant jaw angle width. It also established a more symmetric and smooth jawline coming forward to the chin. A little anterior chin projection was added but creating very minimal chin width. Under general anesthesia and through an exclusive intraoral approach, the custom jawline implant was placed.

Custom Jawline Implant design for Jaw Angle Reconstruction Dr Barry Eppley IndianapolisV-line jaw reduction reversal has to be done using some form of implants. Custom jawline implants are best as the multidimensional jaw augmentation needs are very difficult, if not impossible, to adequately address with any standard jaw angle implant shapes.

Highlights:

1) Unfavorable aesthetic results can occur from jawline reduction (V-line jaw surgery) with loss of jawline definition and tissue support.

2) ‘Reconstruction’ of lost jaw angle and chin from V-line surgery requires a vertical lengthening of the shortened jaw angles and widening of the chin.

3) A custom jawline implant is the best approach to V-line jaw surgery reversal.

Dr. Barry Eppley

Indianapolis, Indiana

February 21st, 2017

Case Study – Double Chin Correction

 

Background: The shape of the chin has a major effect on facial appearance. Since the chin is a projecting facial structure, it highly influences the shape of the face and how defined the neck can look. The shorter the chin becomes the more convex the facial profile becomes and the neck looks increasingly ‘lost’.

A common aesthetic facial concern is that of the Double Chin. This is really an urban term that is a misnomer. It is not really a double chin per se, it is really a chin deficiency or lack of enough chin projection. When combined with even a small amount of excess neck fat, which occurs right under the chin (submental fat), the profile will show two humps or mounds. They may look like two projecting chins but the lower ‘chin’ ir excessive neck fat.

The treatment of the double chin is a classic diametric surgery. Each ‘chin’ change must be in opposite directions to create the best facial profile change. The upper ‘chin’ must be moved forward and requires some type of bony procedure. (implant vs sliding genioplasty) The lower ‘chin’ requires soft tissue reduction using liposuction fat removal. Together the entire lower face is improved as it becomes more ‘pulled out’ and defined.

Case Study: This 45 year-old female was bothered by the increasing size of her double chin as she aged. She has always had a shorter chin but as she had gotten older the ‘double chin’ appeared.

Under general anesthesia an initial small submental incision was made through which the neck was treated by liposuction removing about 12ccs of fat. The submental incision was extended to 1.5 cms and a 7mm thick curvilinear silicone chin implant was placed in a subperiosteal pocket on the bottom of the anterior chin bone. (the implant had no extended side wings)

Double Chin Correction result side view Dr Barry Eppley IndianapolisDouble Chin Correction result front view Dr Barry Eppley IndianapolisHer eight week postoperative result show elimination of the double chin and a much improved facial profile. Between the chin augmentation and the liposuction, it really takes at least six weeks after surgery to see the full benefits of the double chin correction procedures. Depending upon the degree of horizontal (and even vertical) chin deficiency, the chin deficiency may be better done using a sliding genioplasty for a more 3D chin augmentation effect. It also can have a more positive neck reshaping effect as it pulls the underlying neck muscles (roof of the neck) forward and up.

Highlights:

1) The double chin deformity is a combination of excess fat fullness under the chin and insufficient horizontal chin projection.

2) The combination of submental/neck liposuction and chin augmentation effectively treats the double chin deformity.

3) Whether the chin augmentation is best done by a chin implant or sliding genioplasty depends on the degree of horizontal chin deficiency.

Dr. Barry Eppley

Indianapolis, Indiana

February 20th, 2017

Case Study – Pediatric Otoplasty

 

Background: The formation of the ear is an amazingly complex embryonic process. That is evident in just looking at the ear with its spiral array of convexities and concavities of cartilage around the ear canal. It is remarkable that it forms properly and does so twice in most people due to its bilateral presence.

But because of its complexity the ear is one of the most commonly misshapen of all facial features. From minor deformities like earlobe clefts and Stahl’s ear to major malformations like microtia there is a wide array of congenital ear malformations that can occur. One of the most common ear anomalies, and it is questionable whether it should be called an anomaly, is that of the protruding ear. All of the ear is present but its sticks out too far from the side of head due to the lack of an antihelical fold, overgrowth of the concha or some combination of both.

Setback otoplasty, also called ear pinning, is the well recognized surgery for the correction of the excessively protruding ear. It is done in both adults and children. The common question in children is at what age is the proper time to perform the surgery. The underlying premise of this question is when can the surgery be done so that it will not adversely affect growth of the ear cartilage.

Case Study: This 6 year-old male child has very prominent ears due primarily to a lack of antihelical fold development. Where the fold was completely absent the ear stuck out the most. Down near the earlobe some sembence of an antihelical fold was present and the ear stuck out less.

Male Child Otoplasty result front view Dr. Batrry Eppley IndianapolisUnder general anesthesia an otoplasty procedure was performed through an incision on the back of his ears. Minimal skin was removed from the back of the ear and the correction was done principally through multiple horizontal mattress sutures (to create the fold) and some concha-mastoid sutures. (to decrease the auriculo-cephalic angle)

Pediatric Otoplasty result back view Dr Barry Eppley IndianapolisPediatric Otoplasty result side view Dr Barry Eppley IndianapolisHis one month results show a good and reasonable symmetric ear reshaping result. A close-up side view of before and after pictures show that the effect was largely achieved by creating an antihelical fold and a more defined superior crus in the upper helix.

Clinical studies have shown that suture cartilage manipulation of the ear can be done as early as age 2 without any negative growth effects on the ear cartilage. While it can be technically done at such as early age (and I have done so numerous times) there is the important question of postoperative compliance and avoidance of unintentional ear trauma. (which could cause suture disruption and partial ear shape relapse) Between lack of any psychosocial developmental issues in children and performing elective surgery at such a young age, it is far more common to have pediatric otoplasty done closer to age 5 or 6.

Highlights:

1) Congenital ear deformities are amongst the most frequently occurring of all facial deformities of which the protuding ear is the most common one seen.

2) Setback otoplasty (ear pinning) achieves its effect primarily by cartilage bending.

3) The age to perform an otoplasty is largely parent driven in children and be effectively done anytime after age 2.

Dr. Barry Eppley

Indianapolis, Indiana

February 16th, 2017

Buccal Fat Pad for Fat Injections

 

The buccal fat pad is a well known reservoir of facial fat that can be removed in selective patients for a cheek thinning effect. The buccal lipectomy is an impressive procedure when one looks at the size of the fat pad as it is being extracted.

But beyond its potential aesthetic facial benefits, the uniqueness of buccal fat is that it is an encapsulated fat collection and it has a large lobules of fat within it. This suggests that this unique collection of facial fat may be metabolically different than other types of face or body fat. The role the buccal fat pad plays has never been precisely defined but it is not one of being a primary depot (collection) site for excess calories. This raises the question of whether buccal fat may offer advantages in fat transfer. (are the fat cells more hardy if transferred?)

Buccal Fat Pads for Lip Injections Dr Barry Eppley IndianapolisBuccal fat can be processed into an injectable form. The fat pads can be cut into small pieces and then passed slowly back and forth between syringes until it is in more of an emulsified form. It is then placed into one cc syringes for injection. One unique feature of this emulsified fat injectate is that it has a very linear smooth flow as it comes out of the syringe.

buccal fat lip injectionsThe quantity of fat that both buccal fat pads can provide is 10cc to 12ccs. This is more than adequate for many facial augmentation needs such as the lips and cheeks. Whether it may survive better than other fat is speculative. But because it does not require a liposuction harvest suggests that it might have a higher survival rate.

The main drawback to the use of buccal fat for fat injections is that the buccal lipectomy procedure must be concurrently done for an aesthetic purpose. Because it creates its own aesthetic effect buccal fat is not harvested only for convenience.

Dr. Barry Eppley

Indianapolis, Indiana

February 14th, 2017

New Technique in Earlobe Reduction Surgery

 

While often perceived as a myth, the ears do grow longer with age. But it is not really that the ear is growing, rather the earlobe is sagging. As the only non-cartilage supported structure of the ear, earlobes can and do develop ptosis (sagging) The vertical length of the earlobe does get longer with age and can accelerated by heavy ear ring wear.

Many earlobe reduction techniques have been described over the years. They all can be effective in making the earlobe smaller but their skin excision patterns can create some differences on the earlobe shape as well as place the resultant scars in different locations.

In the Online First edition of the February 2017 issue of Aesthetic Plastic Surgery, a paper was published entitled ‘Earlobe Reduction with Minimally Visible Scars: The Sub-Antitragal Groove Technique’. The authors describe a quadrangular earlobe excision pattern which creates an earlobe flap which can be rotated in the excision defect. This places the scars at the ear-facial junction with a back cutting scar along the antitragis, what they call the sub-antitragal groove and at cheek junction. The resultants scars end up in minimally visible locations. This earlobe technique is shown and talked about being done at the same time as a facelift.

Earlobe Reduction Surgery Dr Barry Eppley IndianapolisOf the many available earlobe reduction techniques, this one provides a substantial size reduction without distorting the earlobe. (thanks to the antitragal groove backcut which allows for good flap rotation) This is where it differs from just a simple wedge resection along the facial-ear junction. It does not create an inverted v-shape at the earlobe-facil junction which some patient may desire and is achieved with other earlobe reduction methods.

Dr. Barry Eppley

Indianapolis, Indiana

February 14th, 2017

Case Study – Dermal Graft for Jaw Angle Asymmetry

 

Background: Asymmetry of the lower third of the face is common. While there can be a soft tissue component to it, more times than not it is caused by asymmetry of the bone. the most common location for jaw asymmetries is in the angle area. The mandibular ramus is the L-shaped portion of the jaw and is prone to differences between the two sides in length and/or width.

Jaw angle asymmetry is best appreciated from the front view. Patients particularly notice it in pictures where the face becomes ‘frozen’ and is most easily seen. But because everyone of us knows our faces so well (and more so today because of smart phones and selfies) patients can see it even when others can’t.

The treatment for a jaw angle symmetry due to a deficiency is an implant. Provided the location is known and the implant is the right shape and size, good correction can be expected. But not everyone likes the concept of an implant so alternative options may be considered.

Case Study: This 32 year-old female had a modest jaw angle asymmetry with a deficiency on her left side. The inferior border along the angle lacked the fullness and jawline that the opposite side had. She preferred to use a more ‘natural’ material rather than an implant.

Dermal Graft for Jaw Angle Asymmetry Correction Dr Barry Eppley IndianapolisLeft Jaw Angle Dermal Graft Implant for Asymmetry Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access the left jaw angle bone. Using allogeneic dermis (Alloderm), a 1.5mm thick section was layered into a thicker implant and sutured together to create a linear graft for the inferior border of the jaw angle. It was inserted and laid along the border. No form of fixation was used.

Jaw Angle Asymmetry Correction result Dr Barry Eppley IndianapolisHer 6 month result showed better jaw angle symmetry and an apparently stable result without resorption.

An allogeneic dermal graft would not ordinarily be a preferred facial bone augmentation material. It is a soft tissue augmentation material that purportedly is integrated into the recipient site and replaced by natural tissue. (scar) In my experience it more often behaves like an implant and becomes a well tolerated tissue filler with some fibrovascular ingrowth. For minor facial bone asymmetries where an implant is not preferred, these dermal products can be an option to consider.

Highlights:

1) Lower facial asymmetry is most commonly caused by a bony asymmetry of the jaw.

2) Jaw angle asymmetries can be treated by a variety of implant materials placed on the bone.

3) For patients wary of synthetic implants on the jawline, an allogeneic dermal graft can be used for smaller jaw asymmetries.

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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