EXPLORE
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.

May 29th, 2017

Case Study- Pennant Corner of Mouth Lift for Correction of the Frowning Mouth

 

Background: The smile is one of the most important forms of facial expression. The perception of the entire face changes as soon as one sees someone smile. But the time when one is smiling is far more limited than when one is expressionless. While an expressionless face is supposed to convey no emotion that is not always true.

With aging, and in some people naturally, the corners of the mouth can turn down in the static face. This creates the appearance of unhappiness or anger even when one does not have those emotions. This is very frustrating for those so affected as there is nothing they one can do about this appearance of their mouth. I have heard many patients tell me how this adversely affects their relationships both socially and at work.

Lifting up the downturned corner of the mouth would seem to be improved by a variety of facelifting procedures. Whether it is a lower facelift of a midface lift, neither of these procedures will provide any significant or sustained improvement in correcting the perpetual frown. Only by directly treating the downturned mouth corner can it be favorably changed.

Case Study: This 65 year-old male had a perpetual frown from his mouth corners being turned downward. This negatively impacted his perception of himself to others. He was tired of being told he was unhappy or mad.

Under local anesthesia a pennant-type corner of mouth lift was bilaterally performed.

In this procedure a pennant-shaped segment of skin is removed above each mouth corner down to the orbicularis muscle. The vermilion mouth corner is mobilized by a back cut along the lower lip vermilion and separated from the underlying muscle. A wedge of muscle is removed inferiorly and then left and sewn to the upper portion of the muscle. The mouth corner is then elevated up to the apex of the pennant skin excision and closed in two layers. He also had a subnasal lip performed at the same time for a more complete upper lip rejuvenation.

A three month follow-up showed mouth corners that were at a completely horizontal level. At rest his mouth no longer looked unhappy. Instead he almost looked like there was a slight smile instead…even at rest.

Highlights:

  1. The cornerstone of correction of the frowning mouth is a corner of mouth lift.
  2. The pennant corner of the the mouth lift technique limits the scar line to the vermilion-cutaneous junction.
  1. The corner of mouth lift changes the position of the mouth corner at end of the smile line as well as tucks up the orbicularis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2017

Custom Hip Implants

 

Hip augmentation is most commonly done using fat injections. Even for patients that do not have a lot of fat to harvest, enough can almost always be obtained to fill in indentations or divots on both sides of the hips. But when combined buttock and hip augmentations are needed or in a thin body type, fat harvest sites may be inadequate. In addition, not all fat injections to the hips are successful.

When fat injections is not option or has failed for hip augmentation, the only other option is the use of an implant. There is no standard or preformed hip implants. While some surgeons may try and use implants made for other parts of the body, the hip area requires a unique implant shape. This shape is more like that of a shaped buttock implant but with a lower profile at its peak projection.

Because the length of the hip and its indentation is different for each patient, custom hip implants are most ideally used. Using measurements taken from the patient, the length and width of the implant can be created. The higher projection of the implant is on its superior end and usually does not need to be greater than 3 to 3.5 cms. The implant tapers down to a fine edge on its inferior extent.

Hip implants are placed through a posterior incision placed at the upper-posterior margin of the implant pocket. It is usually no more than 4.5 cms in length. The pocket is dissected down on top of the TFL (tensor fascia lata, outer thigh muscle) along the outer implant markings. The iplants are inserted using a no-touch funnel technique. Their low durometer makes passing through the funnel possible. Drains are often used and stay in place for 3 to 5 days. An above the needle girdle or cross-buttock taping with Mefix serves as postoperative compression.

Custom hip implants provide a permanent augmentation to narrow or indented hips. They are an option when there is inadequate donor sites for fat injections or fat injections that have not persisted. When one has enough fat to do injections this should always be tried first as such injections improve the quality of the hip tissues even if its augmentation effect may turn out inadequate.

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2017

Nanofat Grafting

 

Injectable fillers are the most common method used today for a wide variety of facial volumizing effects. Ideal for patients that want an immediate result that avoids surgery, the selection of almost twenty different fillers provides a filler type for every patient’s needs. Despite these advantages injectable fillers have one major downside…lack or persistence. Despite manufacturer’s efforts to improve their longevity, permanent injectable fillers that have a good safety profile are not on the near horizon.

Fat grafting offers an injectable material that does have the potential for a permanent augmentation effect. Its problem, however, despite this potential is that it is wildly unpredictable. Different intraoperative processing methods and harvest sites have been used but the concept of optimizing fat cell survival remains not completely worked out. In addition, traditional fat grafting creates a thicker more putty like material which does not lend itself well to a smooth linear  injection like that of synthetic injectable fillers.

An alternative fat grafting method is that of micro- or nanofat grafting. In this technique the fat graft is micronized or emulsified into a much more liquid mixture. This can be done by machine or manual technique. The intent here is not too focus on fat cell survival but to create an autologous scaffold by shearing the fat into small particles. This not only adds volume by injection but provides a bio-scaffold framework onto which new tissue ingrowth may occur. If PRP (platelet-rich plasma) is added to the nanofat graft a potent autologous regenerative matrix is created that far surpasses the biologic response to a synthetic injectable filler.

The physical benefit of nonfat injections are that they act like injectable fillers. Their emulsified nature allows them to be injected from very superficially into or just under the dermis or into deeper tissue planes. Such particulated fat grafting has been shown to result in improved skin quality that is maintained out to six months to year

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2017

Case Study – Incomplete Cleft Lip Repair

Background: While cleft lip and palate is a widely recognized orofacial deformity, it is less commonly appreciated that it has a wide spectrum of presentations. It occurs in basic categories of combined cleft lip and palate and isolated cleft lip and isolated cleft palate, but every  possible variation in between these basic categories occurs. Its diverse presentations has to do with the remarkable formation of the upper lip due to the embryologic union (and lack of adhesion in clefts) of the lateral lip and nasal elements.

The incomplete cleft, as the name implies, involves just one element of the lip and palate. Externally this would be an incomplete cleft lip without any palatal involvement. Careful inspection of the incomplete cleft lip, however, shows that there is still some nasal involvement and a notch may also appear on the underlying alveolus as well.

Other than isolated cleft palate, which presents no visible external deformity, incomplete cleft lip would be the next most favorable cleft deformity to have.

Case Study: This 4 month-old female was born with an incomplete cleft lip that spared the nasal sill. There was still nasal malformation with a misshapen nostril. There was no underlying involvement of the alveolus.

Under general anesthesia she had a unilateral cleft lip repair using a rotation-advancement technique. (central lip element rotates downward and the lateral lip element advances in behind it. Primary nose repair was done by alar cartilage dissection and the placement of a small overlying resorbable plate for support.

One year follow-up shows good length and alignment of the philtral column, adequate vermilion fullness and an improved nostril shape. Some visible scarring is seen at the nasal sill. Whether a cleft lip revision will eventually be needed will require years of growth to determine.

Highlights:

  1. The incomplete cleft lip  usually spares the alveolus and palate, making it a more ‘favorable’ orofacial cleft
  2. Primary repair of the incomplete cleft lip is the one cleft lip deformity that has a chance of being a one time surgery.
  1. The incomplete cleft lip repair his usually performed around 3 to 4 months of age.

Dr. Barry Eppley

Indianapolis, Indiana

May 26th, 2017

Custom Buttock Implants

 

Buttock augmentation is most commonly done using fat injections. Known by the term, Brazilian Butt Lift or BBL for short, large volume fat injections can be done to increase buttock size over a broad surface area. While limited by how much fat the patient has to harvest and how much of that injected fat will survive the transplantation process, buttock augmentation by fat injection is usually more successful than not.

When fat injections is not an option for buttock augmentation due to inadequate fat stores or a prior fat injection procedure that has not been successful, buttock implants are the only other buttock augmentation option. Buttock implants offer an assured permanent size increase through the dimensions and volume of the non-resorbable solid implant material.

Buttock implants come in a variety of volume sizes. They can be as low in volume as 250cc up to as high as 700ccs amongst the two U.S. manufacturers. As a general rule, implants under 400ccs can be placed in an intramuscular location but bigger buttock implants have to be placed in a subfascial tissue plane.

While this range of buttock implant sizes can fulfill most buttock augmentation needs, they are not adequate for every patient’s anatomy and size goals. Between the base diameter (width of the implant) and the desired volume, the use of custom buttock implant designs may be needed. With the computer design process, implant dimensions can be tailored to any individual patient needs. Rather than being locked into what is available off-the-shelf, the base diameter and the projection of the implant can be designed from which the final volume can then be calculated.

Most custom buttock implants are larger but the incision needed to insert them remains the same. (7cm intergluteal incisional length) For this reason using a funnel insertion device is important to prevent tearing the low durometer solid silicone gel material whose diameter often exceeds the incisional opening by a factor of 2X.

Dr. Barry Eppley

Indianapolis, Indiana

May 24th, 2017

Bioelectronics Migraine Device Study

 

Headaches are a common human malady and present in many forms that range anywhere from a minor nuisance to that of being debilitating. One of the more severe headache forms is that of migraines. Being a true neurologic disorder, this type of headache is associated with head pain that is both disruptive and causes dysfunction. While their exact pathophysiologic mechanism remains not well understood, drug therapies remain the mainstay of treatment for which they are numerous prescribed medications. While more recent therapies, such as injectable Botox and nerve decompression surgery, have offered symptom reduction for the most severely afflicted, most migraine patients still rely on oral medications whether they are OTC (over the counter) or by prescription.

A newer and alternative therapy to the treatment of migraines are electroceutical devices. These are external devices that are applied directly over the primary migraine location that use electrical signals to create a neuromodulation effect. While neuromodulation typically refers to the use of chemicals to make the nerve work, an external electrical signal strives to change the function of the nerve to either abort to decrease painful nerve transmissions. Such external neuromodulation devices have been successfully used over the supratrochlear and supraorbital branches of the ophthalmic nerve (first division of the trigeminal nerve) in frontal migraines using transcutaneous electrical nerve stimulation (TENS) to reduce the severity or prevent episodic migraines. However, the TENS approach has also been shown to have patient compliance issues due to skin irritation and the unpleasant tingling nature of the electrode contact with the skin.

Another potential electrocuetical device is that of ActiPatch. This external device uses low-power electromagnetic energy through pulsed shortwave therapy technology (PSWT) to deliver its energy into tissue at a rate of 1000 times a second. This device has no user problems or discomfort and has no known harmful side effects associated with its use. The ActiPatch device was recently approved by the FDA for over-the-counter use to treat pain from knee osteoarthritis and plantar fasciitis. Like migraine headaches, knee osteoarthritis and plantar fasciitis are conditions associated with aberrant peripheral nerve sensitization. Therefore it is reasonable to assume that the Actipatch device may have some therapeutic value in the treatment of migraine headaches as well.
The Actipatch migraine study device consists of a small battery-operated coil placed inside of a head band. The device is oriented when the headband is placed directly over trigger site of the migraine. (occipital, temporal or frontal) We are currently seeking patients to participate in a clinical study to evaluate the potential benefits of the Actipatch device in the treatment of migraines. This is a non-reimbursed study in which the specially designed migraine treatment devices will be provided at no cost to the patient to try over a time period specified in the study protocol. Before and after questionnaires will be used to determine patient responses to the treatment based on the pattern/frequency of their migraine headaches. Interested patients may reply to the following email address to determine if they wish to participate. (info@eppleyplasticsurgery.com)
Dr. Barry Eppley
Indianapolis, Indiana

May 23rd, 2017

Scalp Scars in Aesthetic Skull Reshaping Surgery

 

In any form of skull reshaping surgery scalp incisions are needed. While every effort is made to keep them as short in length as possible, some incisional length is needed with a resultant scar. Such scalp scars are unavoidable The question from patients is always what does the scar look like and how does it heal afterwards.

Incisional healing on the scalp from skull reshaping surgery is affected by many factors. These include the thickness of the scalp skin, hair density and hair shaft pattern, where on the scalp it is located and how the incision is surgically made and closed. No matter how the scalp incision heals from skull reshaping surgery it is important to realize that it will NOT look like many scalp scars appear after neurosurgery procedures. What one may find on an image search on the internet about scalp scars is almost always after neurosurgery procedures. While not a criticism of neurosurgery, scalp scars from aesthetic skull reshaping procedures is of paramount importance and are almost as important as whatever is done to the skull bone below it.

In my experience in performing aesthetic skull reshaping surgery, I have made ten observations about the resultant scars from the scalp incisions.

  1. Making the incisions with ‘cold steel’ (scalpels) has the lowest risk of injuring hair follicles. (lasers and electrocautery make for the worst scalp scars)
  2. Incisions must be made paralleling how the hair shaft exists the scalp to prevent injury to hair follicles.
  3. Closure of the scalp incision should be done with deep galeal sutures and either fine skin sutures or small metal clips. The dermis (underside of the skin) should not be sutured to prevent injury to hair follicles. There are no scar differences between small sutures or metal clips.
  4. Scalp scars do best on the top and back of the head. Scalp incisions on the sides of the head (temporal region) have a tendency to widen a bit in some patients.
  5. Scalp scars do very well in bald or shaved heads in men. They often do better than in patients with hair.
  6. Scar widening is more likely in skull augmentation than skull reduction procedures. Less tension on the wound closure equals a more narrow scar.
  7. Longer scalp incisions have a greater risk of scar widening than smaller scalp incisions, presumably due to the magnitude of the procedure done. Although more incision length in general increases the risk of scar widening by virtue of its greater length.
  8. Ethnicity does not change the risk of how the scar heals. Darker skin pigments do not have increased adverse scalp scars than that of Caucasians.
  9. I have never seen a scalp scar keloid, only scar hypertrophy. (widening)
  10. Repeated entry into the same scalp scar increases the postoperative risk of widening.

Dr. Barry Eppley

Indianapolis, Indiana

May 22nd, 2017

Technical Strategies – Z-Plasty Medial Epicanthoplasty

 

The shape of the eyes is affected by many anatomic structures. While much focus is on the larger eyelids, the inner corner of the eyes has a significant impact on eye appearance. While they may the small the inner and outer corner of the eyes affects eye width as well as the angulation of the eyelids.

The epicanthal fold or epicanthus refers to a visible skin fold that covers the inner corner of the eye. While everyone has some degree of an inner eye skin fold, the prominent epicanthal fold is most commonly associated with the Asian eye. (although many other ethnicities have it as well) They can also occur in Down’s syndrome as well as fetal alcohol and Turner’s syndrome. The height of the bridge of the nose is also a factor in its occurrence. Low nasal bridges have a high association with the epicanthal fold while high nasal bridges do not, presumably due to the stretch of the skin between the eye and the nose.

The epicanthoplasty is a procedure done to change the shape of the epicanthal fold. While it is most commonly associated with double eyeliod surgery, it can also be done as an isolated procedure in patients with a distinct upper eyelid fold. In these patients the most common technique is a z-plasty. This eliminates the downslanting fold as well as creates a horizontal orientation of the inner eye.

The inner eye z-plasty is carefully marked with its long axis along the fold and the back cuts at 45 to 60 degrees. The limbs must be marked so the switch of the skin flaps creates the change of the fold. Once cut the skin flaps need to be released of any fibrous attachments to the medial canthal tendon. Small dissolvable sutures are used for the skin closure.

The medial epicanthoplasty has a role to play in the non-Asian eye. It can effectively change the inner eye corner from a down slanting to a horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

May 21st, 2017

Case Study – Breast Implant Replacements with Vertical Lifts

 

Background: Breast augmentation patients present with a variety of breast shapes that may necessitate additional procedures other than just the placement of an implant.Such is the case with sagging of the breasts. While many patients think that an implant will lift a sagging breast, this is not so. While it is true that nipple positions can be elevated by breast implants, that only occurs when the nipple is at or above the inframammary fold. (no breast sagging)

Women that have had breast implants for a long time often present for implant exchange/replacement. This is due to a variety of reasons such as implant failure and the desire for larger or smaller implants sizes. It is common that at the time for new breast implants the breasts have changed from the first time the implants were put in. Due to weight gain/loss, pregnancies and gravity, breast tissue that was once on top of the implant has now slide off of it. This creates a unique form of breast sagging known as implant sagging.

Thus breast implant replacements may necessitate the need for a concurrent breast lift procedure. Whether the implants size is the same, bigger or smaller a breast lift is needed to get the breast mound and nipple back up over the implants.

Case Study: This 47 year-old female had saline implants placed 14 years previously. (400cc size) While her breast implants remained intact, she was not happy with the appearance of her breasts. Her breasts had become saggy as the mound tissue had fallen off of them. She also wanted larger breast implants.

Under general anesthesia she had vertical breast lifts performed as well as replacement of her implants. Her saline implants were replaced with 550cc moderate plus profile silicone implants.

Depending upon how much breast tissue one has at the time of the original breast implant placements will determine to a large degree how the breasts will ‘age’. The more breast tissue one has initially the more likely subsequent tissue sagging will occur. Implant replacments years later may then require a simultaneous lift.

Highlights:

  1. The combination lift and implant operation is a challenging breast reshaping procedure that its associated with a high risk of revision.
  2. There is a delicate balance between the size of the breast implant desired and the amount of lifting needed.
  1. Many breast implants over time will have the natural breast tissue slide off of the implant creating the secondary need for a lift at the time of their implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

May 21st, 2017

Preventing Infections in Breast Augmentation

 

Breast augmentation is one off the procedures in plastic surgery in which the use of an implant is mandatory and is inserted into patients in large numbers. While there are numerous complications that can develop from the procedure, the most dreaded one is infection. Such a complication risks everything with the likely outcome of the need to remove the implant.

The most common reason any implant infection occurs is bacterial contamination and inadvertent inoculation of the implant. While the implant may be sterile in the packaging there are numerous opportunities for it to become inoculated between the box and the implant pocket. While most plastic surgeons use numerous safeguards to prevent infection there are no standards of practice amongst all of them.

In the June 2017 issue of the Annals of Plastic Surgery, an article was published entitled ‘Antimicrobial Prophylaxis Practice Patterns in Breast Augmentation: A National Survey of Current Practice’. In this paper, a surgery was sent to members of the American Society of Plastic Surgeons to assess their practice patterns of preventing infections in breast augmentation surgery. Of all the members solicited just over 250 responses were obtained. The results of the surgery showed that Chlorhexidine was used for surgery site prep in just about 50% of the respondents and a triple antibiotic solution was used for both implants soak (40%) and pocket irrigation (almost 50%) before implant placement. Interestingly over 40% of the surgeons used a no-touch funnel for implant insertion. After surgery antibiotics included a first-generation cephalosporin (Keflex) in almost 80% of respondents and was used up to one week after surgery in about half of the reported surgeon’s practices.

While there was no accompanying reporting of the respondent’s rates of infections, it is clear that an aggressive approach to breast implant infection is generally used that presumably creates a low risk of postoperative infection. Preventing bacterial contamination is being done at multiple levels from surgical site preparation, pocket and implant decontamination to after surgery systemic antibiotic prophylaxis.

In my breast augmentation practice, thus multi-level approach is used to prevent postoperative implant infection. While every level of infection prevention is important, the funnel insertion technique in which the implant is not touched by human hands is an invaluable part of the procedure.

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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