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.

October 15th, 2017

Case Study – Female Refining Rhinoplasty

 

Background: The popularity of rhinoplasty is a combination of the prominence of the nose on the face and the successful outcomes possible from the procedure. It is hard to know the exact gender distribution that undergoes this type of facial surgery but it seems like more females than males have the surgery.

While the nose shapes in women are highly variable, there are common features of the nose that they wish to change. Almost first and foremost is that of the nasal hump or bump. At the least women prefer a straight dorsal line and some even prefer more of a saddle nose or swoop their dorsal profile. The second feature is that of the nasal tip. A wide or drooping nasal tip is not a flattering nasal shape in a female. 

Recovery from rhinoplasty its highly influenced by the thickness of the nasal skin. The thinner the skin is, the less swelling of the nose after surgery that will occur…and the sooner the final result is realized. The percentage of female noses that have thinner skin than men is not precisely known but it seems that it is so. The young thin Caucasian female that comes in for a rhinoplasty often has thinner nasal skin.

Case Study: This young female in her mid-20s presented for rhinoplasty. Her two basic nasal dislikes were the small hump and the wideness of the nasal tip. She had fairly thin nasal skin.

Under general anesthesia, she had an open rhinoplasty in which the nasal hump was reduced to a straight dorsal line and osteotomies done to make a less nasal base beneath the hump. In addition, the nasal tip was narrowed by a cephalic trim and transdomal sutures.

Her 3 month results show a smooth dorsal line and a more narrow tip. The nasal bridge still remains sensitive as expected as bony healing takes much longer for complete healing.

Highlights:

  1. Many women seek nose reshaping changes that are for refinement of small disproportionate features.
  2. Small hump reductions and nasal tip narrowing are two common nasal reshaping requests.
  3. Females with thin skinned noses respond quickly to nasal reshaping surgery that only takes a few months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

October 15th, 2017

Case Study – Hydroxyapatite Reconstruction of Large Pediatric Skull Defects

 

Background: The correction of congenital skull deformities with early cranial vault reconstruction is a well established surgical therapy. Such early skull manipulations are based on two fundamental principles of the infant’s skull. First, the bone is thin and can fairly easily be removed, reshaped and re-inserted. Secondly, the osteogenic regenerative power of the dura at such early ages allows any bone defects around the bone reconstruction to fill in with new bone.

But despite the potential osteogenic capability of the dura in infants, full-thickness bone defects still do occur. Often they are small and are at the junction of reassembled skull bone pieces from the initial reconstruction. But in rare cases the skull defects may be much bigger, reflective of bone defects left behind from large bony advancements from contour expansions.

The reconstruction of skull defects in children can be done by a variety of methods. While bone may be considered an ideal material, the successful splitting of cranial bone in children is not an assured outcome. A variety of synthetic materials and implants are available to ‘patch’ such skull defects. Each has their own unique handling characteristics.   

Case Study: This 9 year-old female was originally born with bilateral coronal craniosynostosis for which she underwent a fronto-orbital advancement at 11 months of age.  At five years of age it could be seen that large full-thickness defects remained that never filled in with bone from the wake of the fronto-orbital advancements.

Under general anesthesia, the skull and bone defects were exposed through her original coronal scalp incision. The bone defects were lined with resorbable mesh plates by separating the dura from the bony edges so the plates could be slide under and be held into place. Hydroxyapatite cement was applied onto the plates and built up to the surrounding bone edges for a smooth skull contour.

After surgery x-rays show the hydroxyapatite cement, which while containing the inorganic mineral hydroxyapatite, is actually more dense than bone even if it is structurally weaker. The long-term of such hydroxyapatite cements is not resorption and replacement with bone. Rather it will serve as as substrate onto which bone will grow across its outer surface, re-establishing a bony bridge across the defects.

Highlights:

  1.   Full thickness skull defects are not rare after infantile cranial vault reconstruction surgery.
  2. While hydroxyapatite cement may be the best reconstructive material choice for the pediatric skull, its weak biomechanical properties are not favorable to be used alone.
  3. Creating a stable floor with resorbable mesh plates allows hydroxyapatite cement to be successfully applied in full thickness skull defects in children.

Dr. Barry Eppley

Indianapolis, Indiana

October 15th, 2017

Technical Strategies – Webbed Neck Correction with Trapezius Myotomies

 

The webbed neck occurs is a wide variety of medical conditions and has variable presentations. While most commonly associated with Turner’s, Noonan and Klippel-Feil syndromes where the webbed necks are severe, they also occur in lesser presentations that may have no specific syndrome associated with them. While non-syndromic neck webbing is less severe, it may be more aesthetically disturbing given that it is a solitary physical deformity.

The traditional methods of webbed neck correction use incisions and tissue rearrangements directly along the neck webs which are aesthetically unacceptable. While effective the visible scarring is not a worthy tradeoff in many cases particularly in the less severe neck webs. For this reason I use a posterior approach that employs a diamond-shaped skin excision. The upper half is in the hairline and the lower half is in the non-hair bearing neck skin. The middle angles of the equilateral parallelogram are placed along the horizontal axis of the maximum amount of inward skin pull needed.

The posterior neck skin is fully excised down to the fascia. It can be surprising how thick the skin and fat is on the back of the neck even in a thin person. Skin flaps are raised out to the lateral neck web lines on each side along the trapezius fascia. The fascia is opened along a linear line that goes out to the neck webs. With the trapezius muscle exposed its fibers are partially released from its lateral border for several centimeters inward. Midline fascial plication is then done on each side pulling in the sides of the muscle.

To complete the webbed neck correction, the skin is closed by changing the diamond-shaped excision into a vertical midline closure. The muscle and fascia work brings in the deeper structures while the skin closure provides the more superficial neck narrowing effect. Skin excision and closure alone will not create a sustained webbed neck corection.

Dr. Barry Eppley

Indianapolis, Indiana

October 14th, 2017

The Value of Flexibility in Custom Skull Implants

 

The use of custom skull implants has revolutionized the treatment of many aesthetic skull deformities. Being able to precisely locate the defect and design an implant from the patient’s 3D CT scan that can augment it provides an unparalleled accuracy in improving head shape contours. This is particularly effective in skull asymmetries or augmenting skull deformities where the outline of the bony contour defect can be clearly seen. But it is also equally effective in general augmentations to built out flatter skull contours.

While the value of 3D implant designing can not be under appreciated in aesthetic skull reshaping surgery, the material composition of the implant is also important. While one would think that a rigid implant that resembles the hardness of bone would be appropriate, this is actually counter productive. Such a firm implant would require a long scalp incision to insert which in many cases would need to be a full coronal scalp incision. This would be aesthetically unacceptable for many patients.

The use of a solid but flexible silicone material is of great value in custom skull implants. As the material has some flexibility, this allows it to be inserted through much smaller scalp incisions. It really is quite analogous to that of breast implants. How does a breast implant with a much bigger base diameter than the length of the incision get inserted? Because the breast implant is malleable and can be temporarily deformed to pass through a small skin hole. While custom skull implant are not deformable as they are a solid silicone material (and not a gel like that of breast implants), they have some flexibility. This material flexibility allows the implants too be bent, rolled or twisted so that it can be inserted. Once the implant is inside the larger tissue pocket, it can be manipulated into position and be unrolled to lay flat.

But because a custom silicone skull implant has some material flexibility, this does not mean it does not feel firm like bone once in place. Like wallpaper on a wall, once in place  with the backing of the bone a custom skull implant will feel just like bone.

Dr. Barry Eppley

Indianapolis, Indiana

October 14th, 2017

Case Study – Knobby Knee Liposuction

 

Background: Excess fat collections can occur all over the body. Some may occur from excess calories (e.g., abdomen) while others occur as part of one’s development. (e.g.,

arms) But regardless of its source, most fatty areas can be successfully treated by liposuction for contour improvement.

Liposuction of the lower extremities is the second most common area requested for treatment after the abdominal/waistline area. This is almost exclusively a female request and historically consisted of the inner and outer thighs. But as liposuction has become more advanced, contour reduction and shaping has extended to the knees down to the ankles. It is no surprise that successful lower extremity liposuction shaping works just as below below the knees as it does above it.

The knees may be a small body area but they have an important aesthetic role in the lower extremities. Being situated midway between the upper and lower leg, they provide an aesthetic breakpoint in the leg. Their inner and outer contours provide a break in the linear line of the leg. A slight outward curve of the knee provides an appealing curvature as long as it is not too prominent. When fatty collections of the inner knee become excessive, they are known as knobby knees.

Case Study: This 42 year-old female wanted to reshape her ‘knobby knees’. Even though she was not overweight she always had  prominent inner knees which stuck out.

Under general anesthesia, she had power-assisted liposuction (PAl) using a 3mm cannula performed on the inner knee. Fat removal extended upward into the inner thigh and into the concavity of the area between the knee and the upper calf muscle for optimal contouring. A total of 200cc of aspirate was removed in each inner knee.

The Inner knees is often overlooked or forgotten as a liposuction treatment area. In reality it is one of the most successful body areas to treat with liposuction because there is little chance of creating a contour deformity and there is also little risk of loose skin afterwards. Conversely the biggest aesthetic risk is under resection leaving too much fat and an inadequate reduction.

Highlights:

  1. The inner knees is a small but effective body area to treat wth liposuction.
  2. An aggressive liposuction approach to treating knee lipodystrophy is needed to make a visible difference.
  3. The area above the knee  as well as below above the calf muscle is need to create shape to the inner knee contour.

Dr. Barry Eppley

Indianapolis, Indiana

October 12th, 2017

Zygomatic Arch Osteotomy in Cheekbone Reduction

 

Narrowing the wide midface can be done only by bringing in the width of the zygomatic arches. The shape and convexity of the zygomatic arch, like a spanning bridge, is what creates the width of the face between the temporal regions of the head and the lower jawline. Moving this portion of the cheek in is done by a dual approach using an anterior intraoral and a posterior preauricular incisions. Once access is obtained the bone cuts can be done by numerous described osteotomy cuts to reduce both the cheek bone and the thinner arch connection to the temporal bone.

In the October 2017 issue of the Journal of Craniofacial Surgery an article entitled ‘Advantages of a Beveled Osteotomy on the Zygomatic Arch During Reduction Malarplasty’ was published. In this paper the authors describe beveling the osteotomy cut on the posterior zygomatic arch. This has numerous purported advantages including

enhancing bony healing by increasing the cross-sectional area for bone contact between the cut edges, decreasing palpability on the osteotomy site, placing the osteotomy more posteriorly, preventing depression in the anterior cheek region, and reducing the need for metal hardware.

Beveling of posterior zygomatic arch osteotomy in cheekbone reduction is a technique that I have always done. It allows the cut end to be pushed inward like a sliding wedge and does avoid the use of metal hardware in an area where it can be more difficult to apply. A straight cut may allow the end of the arch to be pushed in a bit further but not appreciably more than a beveled osteotomy cut.

Dr. Barry Eppley

Indianapolis, Indiana

October 9th, 2017

Five Concepts about Temporal Reduction (Wide Head Narrowing Surgery)

 

Reduction of the wide head is a procedure primarily performed by removal of the posterior temporal muscle. (temporal reduction) Besides the fact that few patients and surgeons even know such an aesthetic operation can be performed or exists, it is common that those who discover it grapple with why it works or have concerns about potential adverse functional facial effects. From that perspective let me address five concepts about temporal reduction surgery.

The Width of the Posterior Temporal Muscle Is Bigger Than One Thinks. The thickness of the side of the head above the ears is composed of three main tissues; skin, muscle and bone. While the temporal bone does make a major influence on side of head convexity, the posterior temporal muscle can often make up 40% to 50% of its thickness as well. In many male patients I have seen the muscle be 7mm to 9mm in thickness per side.

A Vertical Line from the Top of the Ear is the Excision Boundary. The anterior extent of the posterior muscle removal is determined by this line. Albeit somewhat arbitrary as there is more real defined transition between its anterior and posterior bellies, it is were the muscle starts to become much thicker. It is also a convenient point of access from the postauricular sulcus incision placed behind the ear.

Removal of the Posterior Temporal Muscle Causes No Jaw Dysfunction. Seemingly defying the purpose of its very existence, no long or even short-term jaw dysfunction has ever been encountered. If the patient opens their mouth really wide in the first day or two they may feel so tightenness/discomfort but this quickly passes. Undoubtably this occurs because the much larger anterior muscle belly remains (it makes up 70% of the overall temporal muscle mass) and the posterior belly makes an adjunctive but not essential contribution to jaw movements.

The Overlying Fascia of the Posterior Temporal Muscle is Preserved. Keeping the tight overlying fascia allows it to have a contouring effect. Initially the cut edge of the muscle will have a palpable step-off. The overlying fascia has a dampening effect on the remaining muscle edge and acts as a barrier to prevent skin adhesion directly to the now exposed bone. Its preservation also maintains the overlying vascular pedicle of the posterior branch of the superficial temporal artery.

Posterior Temporal Muscle Removal Takes Six Weeks To See Its Final Result. The dressing applied right after surgery is removed the following day. At its removal the flattening result is immediately apparent and usually satisfying. But then the swelling sets ion and it will be another 6 to 8 weeks before the initial result seen recurs.

Dr. Barry Eppley

Indianapolis, Indiana

October 9th, 2017

Case Study – The Limited Facelift Concept

 

Background: One of the most recognized anti-aging facial procedures is that of the facelift. While commonly recognized it is not commonly understood by the public. Many misconceptions exist about this operation from how it is performed, its immediate and long-term facial effects and to who may even be a good candidate for it.

The facelift procedure has been around for over 100 years and its medical name, rhytidectiomy or the removal of facial wrinkles, speaks to its age. In its original use it was designed to remove wrinkles from the face by cutting out skin in front of the ear or temple area. The operation has certainly evolved since its inception, due to improved anesthesia and surgical techniques, and it has become as much about repositioning of lax facialk tissues as it is about cutting them out.

Despite the evolution of the modern day facelift and its myriad of technical maneuvers within the operation, there are still some basic components to it. The extent of skin flap elevation in the face, how the SMAS layer is managed and how much central neck work is done allows for the facial procedure to be divided into three types or levels whose application depends on the extent of the patient’s aging facial tissues.

The limited or mini-facelift, aka level 1 procedure, has become popularized under a variety of marketing names. Because it is a more limited operation it has become promoted for its quicker recovery, shorter operative times and execution under more limited anesthesia methods. By definition such intra- and postoperative sequelae occur because the operation is less invasive. Less surgery is done, thus making everything about this type of facelift ‘less’ even including cost.

Case Study: This 45 year-old female wanted to reverse some adverse changes that had occurred in her neck and jawline. She had developed some jowls as well as some neck skin laxity occur with some platysmal banding.

Under general anesthesia, she had a limited facelift performed with short skin flaps raised in front of the ear and down into the neck but did not extend to the central neck. A short SMAS flap was raised with suture suspension. A submental incision was made to release and tighten the platysmas bands. Her six week results show a smoothing of the jawline and an improved neck angle.

Any ‘limited facelift’ technique is, by definition, a limited version of its more complete form. What makes it easier in every aspect is that it is less surgery. While that may seem obvious it it important for patients to understand that, while everything about the operation is appealing, it will not create the same result as its much larger form. It works best when the operation is matched to the anatomic problem. For patients with greater neck sag, jowls and overall tissue descent, this operation will not meet one’s expectations. In short a limited facelift is not a full facelift.

Highlights:

  1. A facelift is a variable operation whose extent is based in the aging anatomy that it needs to treat.
  2. A limited or mini-facelift is usually defined as a procedure that does not include the full neck dissection and/or has limited skin flap elevations.
  3. Most more limited facelifts are best done ion younger patients who have earlier rather than advanced signs of facial aging.

Dr. Barry Eppley

Indianapolis, Indiana

October 8th, 2017

Product Reviews – Botox for Forehead Wrinkle Lines

 

Botox is the most popular form of injectable aesthetic therapt. It has an established history of success in managing problematic facial movements that cause undesirable facial expressions and ultimately skin wrinkles. It was formally FDA-approved well over a decade ago for the treatment of glabellar (between the eyebrow) wrinkles lines and has gone on to receive a similar FDA-approval for crow’s feet wrinkles as well.

Even though formal approval for other types of adverse facial wrinkles and expressions did not exist, Botox has been long been done ‘off label’ by just about every injector that has ever used it. Other aesthetic facial issues such as in horizontal lines across the upper nose (bunny lines), in the neck for platysmas bands as well for the downturned mouth corners, to name a few, are widely done.

Recently Botox was FDA-approved for the treatment of horizontal wrinkle lines. Long a companion injection site with that of glabellar wrinkle lines, it now official that it can be used in this facial area as well. It has been common to treat vertical glabellar and horizontal forehead lines as a combined injection treatment. I would say that it is more common to treat both areas together that it was to treat the glabellar area alone.

What does FDA-approval of this Botox use really mean? It really just substantiates what every injector has observed…that is both safe and effective for use in the forehead. Clinical trials reported by Allergan demonstrated that Botox injection was more effective than a placebo in reducing the severity of forehead lines.

Botox injections creates this forehead effect by temporarily weakening the frontalis muscle which runs vertically across the forehead. Less frontalis muscle movement softens existing deep wrinkles lines and prevents new ones from forming. Its duration of effect is the same as anywhere else on the face with an effect of three to four montyhs.

Dr. Barry Eppley

Indianapolis, Indiana

October 6th, 2017

Case Study – Sliding Genioplasty Combined with Chin Implant

 

Background: Routine chin deficiencies are well managed by with an implant or a sliding genioplasty. The concept of a routine chin augmentation, in my experience, generally falls into a horizontal chin position movement of 10mms for less. Once the aesthetic need becomes greater than a centimeter there is undoubtably an overall lower jaw skeletal deficiency that should ideally managed by a combined orthodontic-orthognathic surgery approach.

But some lower jaw deficient patients will never undergo movement of the entire lower jaw and teeth positions for a variety of reasons. They may appear just for chin augmentation only as a camouflage approach to their lower facial deficiency.

While a large chin implant can be used, most standard chin implants do not provide more than 10mms of horizontal advancement. While larger custom chin implants can be made, such a load of synthetic material on the chin may exceed the soft tissue stretch to safely accommodate it. The projection off such a large chin implant may also appear unnatural with a much thinner jawline behind it.

A sliding genioplasty can usually exceed 10mms if the bone thickness will allow it. I have seen it often go to 14 to 16mms. But in such large tiny chin movements there will be pronounced stepoffs on their sides and the labiomental fold will definitely get much deeper as the bone underneath it has become deeper as the lower chin point comes forward.

Case Study: This young male has a large chin deficiency with a skeletally short lower jaw. From an ideal chin projection standpoint for a male (vertical line dropped down from the lips) he was 22mms horizontally short. Orthognathic surgery was not an option that he wanted to pursue.

Under general anesthesia, an intraoral sliding genioplasty was performed with 14mms of horizontal advancement based in the limits of maintaining bone contact. (lingual cortex of lower chin segment with buccal cortex of upper chin segment) To add a little extra to the what moving the bone achieved a 5mm extended anatomic chin implant was placed in front of the front edge of the chin bone. The wings of the implant went back along the sides of the advanced chin segment across the step off area. Due to the large step-off created an hydroxyapatite block was placed to prevent a severe deepening of the labiomental fold. (the fold is always going to get deeper in larger chin augmentations, you just want to try and lessen that effect)

The need for a combined sliding genioplasty and implant for aesthetic chin augmentation is rare and is avoided by the traditional use of orthographic surgery. The value of such a chin implant is three-fold; 1) its a small amount of additional horizontal augmentation, 2) its wings can cover up the indentation along the sides of larger sliding genioplasty movements (the concave jawline deformity) and 3) it keeps the chin from looking too thin in the frontal view.

It is not a mortal surgical sin to combine two chin augmentation methods that are often viewed as competitive procedures. Each has their own distinct aesthetic effects and in rare cases may be used synergistically to create a better aesthetic outcome than either one can achieve alone.

Highlights:

  1. Large chin deficiencies are often beyond what a sliding genioplasty or a chin implant can effectively treat alone.
  2. Combining a sliding genioplaty with a chin implant can maximize the amount of horizontal advancement and cover bony step offs on the sides. 
  3. Large sliding genioplasty movements will require fill of the step-off to avoid a severe deepening of the labiomental fold.

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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