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.
November 26th, 2015
Background: The shape of the forehead is affected by various hard and soft tissue components. The forehead is framed by the hairline superiorly, the brows inferiorly and the bony temporal lines to the sides. The projection of the forehead is controlled by the thickness of the frontal bone and its degree of convexity and smothness. The height of the forehead is judged by the vertical distance from the hairline to the brow.
Vertical forehead reduction can be of benefit when the hairline to brow distance is about 6.5 cm and longer. Numbers aside, one knows when the forehead is too long by their own aesthetic sense. Shortening the length of the forehead is done by moving the hairline forward or more inferior through extensive scalp undemining and mobilization. A powerful procedure, the hairline or scalp advancement can make a dramatic difference in the appearance of the upper third of the face.
Bony forehead reduction is done to either narrow the shape of the forehead or eliminate any obvious bony projections. This is a bone burring technique that is usually done to narrow the width of the forehead, reduce the amount of its forward projection (convexity) or smooth down so called forehead horns. This almost always need to be done through an open approach afforded by a hairline incision.
Case Study: This 40 year male had a long forehead due to receding frontal hairline and a wide and bulging forehead due to its bony shape. He had a prior hair transplant procedure with a linear strip scar on the back of his head. His desire was for a shorter forehead length and a less wide and bulging forehead.
Due to his prior hair transplant harvests from the back of his head, it was elected to do a first stage scalp expansion to ensure enough scalp could be mobilized for the hairline advancement. This was done using 120cc of scalp expansion by fill volume. During the second stage through a hairline incision, the tissue expander was removed, the bony forehead reshaped by burring and the hairline advanced 2 cms. Small temporal rotational scalp flaps were also done to eliminate the temporal recession areas.
Total forehead reduction can be done through bony contouring and a hairline advancement. Using the ‘central’ pretrichial hairline incision positioned between the forehead and the scalp, both forehead reduction procedures can be successfully done. His history of strip occipital harvests for hair transplants did necessitate a first stage scalp tissue expander which would not normally be needed in most cases.
Many patients with high and long foreheads have a combination of a posteriorly recessed hairline and bony forehead bossing. Preoperative computer imaging will show whether the apparent forehead bossing is a function of just a high forehead and an exposed upper forehead bony contour or whether a true excessive forehead convexity exists. A very wide or broad forehead in the frontal view, however, is an excessive bony width problem for which a hairline advancement will not improve.
- Forehead bossing is treated by bony reduction of forehead width and projection. (forehead contouring)
- Vertical forehead reduction is a soft tissue procedure where hairline advancement is done. (scalp advancement)
- Total forehead reduction is when both bony and soft tissue procedures are done simultaneously.
Dr. Barry Eppley
November 24th, 2015
A sliding genioplasty is a very versatile chin reshaping procedure that has been used for decades. In elective chin augmentations it is the alternative option to the use of a chin implant. Although chin implants are by far more commonly done in a ratio of at least 20:1 if not greater. While chin implants are a simpler procedure they are not appealing to everyone nor are they always the best choice for every type of chin deficiency.
A sliding genioplasty is usually best done for younger patients who have significant chin deficiencies. There also is a much higher tendency to them at the time of orthognathic surgery when other facial bones are being manipulated as well. In larger chin deficiences moving of the bone has less potential for any long-term problems than does an implant.
The limits of how far forward a sliding genioplasty can move the chin horizontally is a function of the thickness of the chin bone. It is important to maintain some bone contact between the upper and lower chin segments, meaning the back edge of the downfractured chin segment should at least touch the front edge of the chin bone above it. (and be stabilized by plate fixation)
But in some larger chin deficiencies even maximal forward chin bone movement may still leave one with less than an ideal profile change. In these circumstances, whether recognized during the initial sliding genioplasty or afterwards, the solution can be a chin implant. A chin implant can be placed on the front edge of the sliding genioplasty to gain an additional 3 to 5mms of horizontal chin projection. An extended anatomic chin implant is used so that its wings cover the step off area on the back side of the osteotome line. It is critically important that the chin implant is secured by screw fixation to the sliding genioplasty segment.
While chin implants and sliding genioplasties are traditionally thought of as being mutually exclusive, they do not have to be. In need of extreme amounts of chin projection, the combination of a sliding genioplasty with a chin implant overlay can be a useful chin augmentation strategy.
Dr. Barry Eppley
November 24th, 2015
Background: While the effects of breast implants can last a lifetime, the implants themselves may need to be replaced due to mechanical failure. This is a well known reality of breast implants and the younger of age one has them placed the near 100% probability they will need to be replaced over one’s lifetime.
But other reasons breast implants may be replaced can be either a physical or psychological one. The breast tissue around an implant may decrease with aging or the overlying skin can become more stretched and a sag develop. A women may also perceive a different breast size ‘need’ at a different time or place in life as her body or social circumstances have changed.
Case Study: This 42 year Asian female who weight 130 lbs wanted larger breasts using 375cc silicone gel breast implants. While she had a little bit of breast sagging, it was not enough to warrant any form of a breast lift. Through an inframammary incisions, the silicone breast implants were placed in a partial submuscular plane. (dual plane positioning)
She was not seen again after her six week checkup appointment until ten years later. While her breast tissues had relaxed a little over the years, there was not substantial change in their shape that could be perceived. In essence, her breast augmentation result appeared to be very stable with no change in implant position or loss of breast parenchyma. (breast tissue)
What brought her back ten years later is that she had lost ten lbs and now felt her breast implants were too big. She now desired smaller implants and breasts that were positioned higher up on her chest. This os going to require a concomitant vertical breast lift with her new smaller breast implants.
While breast implants do not change themselves, the body and the mind’s perception of them can. Pregnancy and weight loss, for example, can result in loss of overall breast size and also result in tissue sag off the implants. Also as women age their perception of breast size may change and there may be a perceived need to go bigger or smaller depending on a variety of personal factors.
- The long-term effects of silicone breast implants is well studied as plastic surgeons have seen many such patients often as long as three or four decades after implantation surgery.
- While breast implants themselves are usually dimensionally stable, it is the breast tissue around them that can change based on a variety of individual patient issues.
- Besides the breast tissue changing on top of implants, patients may also change their attitudes and objectives with them.
Dr. Barry Eppley
November 23rd, 2015
Background: Reshaping of the entire jawline to a more slim or narrowed shape has become known as V line surgery. It is most commonly done in Asians to change a wide and more square jaw to a more narrow and triangular one. It is a bony reshaping surgery which focuses on the chin anteriorly and the jaw angles posteriorly
The cornerstone of V line surgery is what happens in the anterior chin area. As the most projecting point of the lower jaw it must become less wide and often times vertically shorter or longer depending on the patient’s natural chin shape. This is usually done by various of osseous genioplasty concept where the chin bone is downfractured, a midline resection done and then put back together. A horizontal wedge reduction can be done to shorten it if the chin is initially vertically long or the reassembled chin can be put back together and brought forward for a horizontally deficient chin.
The secondary part of V line surgery is a change in the width of the jaw angle. In the past the jaw angle was merely amputated or cut off. While very effective this wipes out any jaw angle shape and can be prone to create soft tissue sag due to loss of ligamentous and muscular attachments. Today it is recogized that preserving the jaw angle shape is important and angle reductions can be done by either a burring reduction or an outer corticotomy.
Case Study: This 22 year Asian female was undergoing a variety of facial reshaping procedures including V line jawline reshaping surgery. She had a naturally short flatter chin and needed more horizontal projection as well as narrowing
Under general anesthesia, she had an intraoral horizontal chin osteotomy done with a midline wedge resection. The bones were put back together with 1.5mm plate and screw fixation and advanced 5mm. The bony stepoffs at the inferior border were trimmed behind the back edge of the osteotomy line. Through different intraoral vestibular incisions the jaw angles were reduced by rotary burring, reducing the outer cortex almost to the marrow space.
At six months after surgery she had a much improved jawline shape. Due to the desire to have further horizontal chin projection, a secondary procedure was done to add a small curvilinear central chin implant of 5mms to create the final jawline shape now seen.
V line jaw reshaping surgery is technically challenging and requires expertise in chin osteotomies as well as mandibular ramus surgery. Secondary revisions are not rare and may need to be done to correct any residual bony asymmetries or projecion deficiencies.
- V line or jawline narrowing surgery is often a combination of chin and jaw angle bony changes.
- The most important element of v line surgery is the anterior chin which must be narrowed and often lengthened to create most of the effect
- Jaw angle width narrowing may also be necessary but it is important to avoid obliterating the shape of the jaw angle in doing so.
Dr. Barry Eppley
November 22nd, 2015
Background: Skull deformities of the back of the head are very common. It is probably the one skull area that has the greatest incidence of shape distortions. This likely occurs because it is the most exposed skull area to deformational force both in utero and after birth due to fetal and neonatal positioning. Thus flat spots on the back of the head are common and occur in a wide variety of locations and extent.
Aesthetic reconstruction of the flat back of the head can be done by a variety of implant techniques. The most common skull reshaping technique today is the use of a custom occipital implant made from the patient’s 3D CT scan. This works well for large flat spots on the back of the head (brachycephaly) as well as those that are associated with some significant asymmetry. (plagiocephaly)
While a custom implant would also work well for smaller flat spots, the cost and the time of manufacture for some patients may exclude this as a treatment option. The use of traditional cranioplasty bone cements, such as PMMA, provide an immediate and relatively low cost skull implant option that can be done immediately and with good long-term results. The key to its aesthetic use is a small incision and getting good shaping of the material as it cures.
Case Study: This 31 year male was bothered by a very discrete flat spot on the central area of the back of his head. It created a sharp step-off at the very end of the sagittal skull area, creating a 90 degree angle between the top of the head and that of the back of the head. Due to cost and being from out of the country, a custom implants was not an implant option.
Under general anesthesia in the beach chair position, a 5.5 cm horizontal scalp incision was made at the bottom end of the flat spot. Through this incision antibiotic impregnated PMMA cranioplasty bone cement was mixed and 40 grams of it as introduced under the widely raised subperiosteal scalp flap over the flat spot. The cement was shaped externally and allowed to set with a focus of smooth edges around the cement’s perimeter. A good intraoperative back of the head contour was obtained.
At one week after surgery both profile views of the back of his head showed good shape improvement. It takes about three more weeks for all scalp swelling to completely resolve. He had simultaneous otoplasty procedures as well hence the bruising around his ears.
A minimal incision PMMA bone cement cranioplasty relies on shaping the material in a blind fashion once placed into the created pocket. There is no forgiveness for any edge transition or step off problems between the cement and the bone since is no way to access them for adjustment (burring reduction) through such a small incision. This is a learned cranioplasty techique that takes a lot of experience to do consistently well.
- Defects of the back of head (occiput) occur in a wide variety of shapes but a flat spot is often the predominant problem.
- The use of PMM bone cement can be used for selective flat spots on the back of the head.
- A small or minimal incision approach can be done for a PMMA bone cement occipital cranioplasty but placing and shaping the cement is a learned skill.
Dr. Barry Eppley
November 22nd, 2015
Chin implants are the most common permanent method of facial augmentation. Chin implants of various materials have been used for almost fifty years. Whatever the material composition of the implant is and its shape and size, chin implants can be introduced from either a superior approach (intraoral mucosal incision) or from below. (submental skin incision) There are advantages and disadvantages of either incisonal approach as well as surgeon advocates for either chin implant introduction technique.
The submental incision for chin implants offers the most direct access to the bottom of the chin bone where the implant should be properly placed. It also provides a pocket which eliminates the risk of any upward migration of the implant provided the pocket is not made too high. Firm fixation of the implant can also be done to the bottom edge of the bone to ensure its midline positioning. Because of a sterile skin prep, it also has a very low risk of infection. From a recovery and potential complication standpoint it also does not disrupt the superior attachment of the mentalis muscle. Its only real downside is that it does create a scar under the chin which can be objectionable to some patients.
The intraoral approach offers a scarless method for chin implant augmentation as its main advantage. Because of going through the mouth (although this is not exactly true because the lower lip is pulled out and away from the oral cavity) and detachment of the superior mentalis muscle, many surgeons feel that it is associated with a higher rate of complications. Superior malposition of the chin implant is actually the most common problem with the intraoral approach.
Several modifications of the intraoral approach can avoid most of the potential chin implant problems. First the intraoral incision should be vertical in orientation, paralleling the fibers of the mentalis muscle. This splits the mentalis muscle but does not separate the mentalis muscle attachments. With the lip pulled away from the teeth, it provides the angle to develop the subperiosteal pocket along the inferior edge of the anterior mandible. Secondly, implant sizers are used to ensure that the pocket has been properly developed prior to inserting the formal chin implant. Lastly, the implant is inserted, positioned and then secured in its midline position with a single 1.5mm microscrew to prevent superior implant migration.
The intraoral approach for chin implants is sometimes preferred by patients with more pigment in their skin, females and any patient that wants to avoid an external skin scar. The incisional technique should be different than that needed for a sliding genioplasty and other chin surgeries with a more limited and less dissected approach By so doing all of the potential disadvantages of the intraoral chin implant approach can be avoided.
Dr. Barry Eppley
November 21st, 2015
Background: A well shaped and toned abdomen is a goal of both men and women of all ages alike. While some have it naturally, particularly at a young age, most have to work to maintain or create it through some regular diet and exercise. A trim waistline and a flat abdomen is a reasonable and attainable goal for many people and would make most happy. But there are a few others that have more loftier desires for their abdominal shape, an abdomen that has visually evident muscular outlines.
The so-called six pack or eight pack abdomen is one that has a midline vertical linea alba between the rectus muscles as well as their horizontal inscription lines evident. These are most commonly seen in young teenage boys and dedicated athletes and body builders. The one common denominator that they share is a very low percentage of body fat which results in such a thin subcutaneous layer of fat that the outlines of the abdominal muscles are seen.
But some patients, usually men, desire to have a well defined abdomen even if they can not create it by a low percentage of body fat and exercise. The artificial approach to creating this abdominal effect is known as abdominal etching or six pack abdominal surgery. This is a unique form of liposuction that removes a linear layer of fat over the vertical and horizontal muscle lines. This allows the overlying skin to indent inward along the lines of fat removal creating the muscle outlines rather than the muscle enlarging to achieve it.
Case Study: This 52 year male has lost fifty pounds and had gotten himself into a much improved shape through his own efforts of better eating and exercise. While he had made major improvements with a near flat abdomen and better waistline, he wanted to improve his abdominal result even further through a surgical approach.
Prior to surgery he had markings made for the vertical midline and the vertical outer borders of the rectus muscles as well as the three paired horizontal inscription lines. Under general anesthesia, a 4mm basket cannula on a powered-assisted liposuction device was used to aggressively remove fat along all linear markings through small incisions. At the completion of the procedure linear strips of foam were placed along the etch lines and covered with a compression garment.
At six weeks after the procedure his abdominal etch lines were becoming apparent as the skin contracts down to the reduced linear subcutaneous fat layers. Further definition in the abdominal etch lines would be expected to continue to develop up to three months after the procedure.
Abdominal etching is a linear liposuction technique that does something liposuction is normally not intended to do…remove fat to deliberate create a focused skin indentation. Abdominal etching works best and looks the most natural in those patients who are already thin with a low percentage of total body fat.
- Abdominal etching strives to create the midline linea alba and the horizontal inscription lines of the abdominal muscles.
- Abdominal etching is a specialized form of liposuction that uses a linear line of maximal fat removal to create its effect.
- The best results in abdominal etching come from those who have a thinner subcutaneous fat layer over their abdomen.
Dr. Barry Eppley
November 18th, 2015
Background: The need for augmentation of the nose can be due to congenital, traumatic or iatrogenic saddle nose deformities or for elective ethnic rhinoplasty surgery. Ethnic rhinoplasty indications are usually for the Asian or African-American patient in my practice and are dorsal line augmentations that usually involve the tip as well. The debate is such nasal augmentation is always one of using the patient’s own tissues (cartilage) or that of the a nasal implant.
The debate of an autogenous vs. alloplastic rhinoplasty is not new and the advantages and disadvantages of both are well known. An implant rhinoplasty simplifies the operation, provides and assured shape and saves the patients any extranasal graft harvest site. But it is an implant and with that comes an increased risk of infection and the potential for ong-term tissue thinning and exposure. Conversely the need for a substantative cartilage graft requires a rib graft harvest with an uncomfortable donor site and scar and the potential for warping of the dorsal graft. But a rib graft has a very minimal risk of infection and no danger of long-term tissue thinning or extrusion.
Nasal implants often have a bad reputation in the mind. of many plastic surgeons. There are certainly easily findable major complications from them that can be located on the internet. But like all surgical implants of any type, how and when they are used plays a major role in their ultimate success and failure. Large nasal implants, dorsocolumellar implant styles that cross the tip area, and noses with thin tissues all increase the risk profile of what is really a subcutaneous synthetic implant.
Case Study: This 24 year Asian female was undergoing numerous facial reshaping procedures of which one was that of a rhinoplasty. She desired a higher bridge from the radix down to the tip. A nasal implant vs a rib graft was discussed thoroughly and she opted for the nasal implant.
Under general anesthesia she had an open rhinoplasty through which a silicone implant was used for the bridge and a septal cartilage graft for the tip. The bridge was built up with a medium Implantech dorsal nasal implant that had 3.5mms at the radix and 4mms at its lower end which was placed under the dome. The nasal tip had increased projection through a septal columellar strut graft and tip suturing techniques.
At six months after her implant rhinoplasty she had a nice straight nose with a higher dorsal projection. Smoothness and straightness of the dorsum are the aesthetic advantages offer by an implant. This style of dorsal nasal implant is fairly narrow in width and is best used in women and not men for this shape reason. A pencil thin nose in men is usually not an ideal nasal look.
Nasal implants can be used very successfully if they are not asked to do too much augmentation and in the carefully selected patient. Limiting the augmentation to the dorsum and not the nasal tip and avoiding excessively high amounts of augmentation will help diminish the risk of complications with their use to very low levels.
- Nasal implants often have a bad reputation when their success is tied more to their use and the patient’s nasal augmentation needs
- Dorsal nasal implants have a high rate of success when the amount of augmentation needed is not excessive.
- Nasal implants avoid the need for a rib graft harvest and offer a more assured straight nose that permanently stays so.
Dr. Barry Eppley
November 17th, 2015
Back or buttock dimples, often called the Dimples of Venus, are believed by some to be a mark of beauty. (Venus = Roman goddess of beauty) They are bilateral skin indentations on the lower back just superior and lateral to the top of the intergluteal cleft. Some people have these lower back dimples while others do not. It is a genetic feature which can be inherited.
Anatomically they relate to the sacroiliac joints and are created by the ligaments which stretch between the posterior superior iliac spines and the skin. In spine surgery they are known as the lateral lumbar indentations which serve as landmarks for finding the superior articular facets of the sacrum as a guide to placing sacral pedicle screws.
For those who seek to have them, they may or may not be attainable. Lower back strengthening exercises are purported to create them but I have no direct evidence that this is true. While the lower back can certainly be strengthened, it is not clear how that would create indentations over the sacroiliac joints unless one already has a hint of them.
The only way to create lower back dimples is to selectively remove any subcutaneous fat between the skin and the underlying fascia of the sacroiliac joints. Injectable options do exist and could be attempted by one of two compounds. High dose steroid injections (Kenalog 40) is well know cause fat atrophy but may thin the overlying skin as well. Deoxycholic acid injections (Kybella) are more selective for dissolving fat without affecting the overlying skin. It would likely need more than one injection session to be optimally effective.
So called Dimple of venus surgery is fat removal limited to the desired dimple area. To be successful one had to have some subcutaneous fat to remove. Small or microcannula liposuction done under local anesthesia is one surgical option. Another approach is to make a small vertical incision and directly excise fat and sew the dermal skin edges down to the fascia with a single buried suture.
Dr. Barry Eppley
November 12th, 2015
Plagiocephaly is a term used for a broad collection of congenital skull deformities that involve a general twisting or rotation of the skull base. This is most commonly seen as flattening on one side of the back of the head with compensatory changes anteriorly to the forehead and face. When diagnosed early skull molding therapies with helmets can be very effective in lessening the head shape deformity. But if not treated within the first year of life, the success of cranial molding therapy decreases significantly.
Unlike more severe skull deformities like craniosynostosis, plagicephaly is not generally viewed as severe enough in many cases to warrant major intracranial surgery through bone removal and reshaping. Flat areas on the back of the head are viewed as ‘cosmetic’ with no medical indication for surgical intervention…as viewed from the typical craniofacial surgical perspective. Certainly it is hard if not impossible to justify a major operation with a long scalp scar and need for blood trasnfusions to correct a mild to moderate occipital skull shape problem in a young child.
It is common in my practice to correct a wide variety of skull shape issues in adult with ‘aesthetic craniofacial’ techniques. This essentially means two fundamental approaches that differ from traditional craniofacial surgery methods…a very limited scalp scar and correction of the deficient skull with onlay bone cement methods. This requires experience in working with a variety of alloplastic cranioplasty materials and doing so with limited incisional access. This has proven to be a very effective approach with good skull contour improvements.
There is no reason that such a limited incisional skull contouring procedure can not be safely and effectively applied to young children with plagiocephaly skull concerns. The key component to this approach is the type of contouring material (bone cement) that is used. A bone cement material like hydroxypatite cement, while synthetic, has a highly osteoconductive surface and allows bone to bond directly to it. (does not develop a scar interface like a truly synthetic material would) While never being resorbed and replaced by actual bone, it is extremely well tolerated and will allow any remaining skull growth to be unimpeded. (At three to four years of age, the skull has undergone over 70% of eventual skull size anyway) Thus the skull contouring effect achieved will be maintained as the child continues to grow.
Having done a small series of hydroxyapatite cement skull augmentations in children (under age 5) for flat spots on the back of the head, it is an effective procedure with a very quick recovery. Most scalp incisions have been less than 5 to 6 cms in length. It is a challenge to work with bone cements through such a small opening but years of experience with the material have helped tremendously. For the very motivated parent(s), treatment of mild to moderate plagiocephaly can be vey safely done at a young age.
Dr. Barry Eppley