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Plastic Surgery
Dr. Barry Eppley

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

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

February 18th, 2018

5-FU Injections in Rhinoplasty

 

Rhinoplasty surgery produces an expected amount of swelling and bruising based on the extent of the surgery. Like all facial surgeries the swelling and bruising is temporary and takes time go resolve. The swelling from rhinoplasty, however, is well known to be prolonged and is most manifest in the tip area. The tip swelling can be quite prolonged and it is well known that it can take a year or even longer to see the final remnants of the swelling to have dissipated and the remodeled tip shape to appear.

Fortunately for most rhinoplasty patients the final shape of the nose does not usually take a full year and an acceptable result occurs much sooner. But in the thick-skinned nose patient the swelling that will occur and the time is takes to go down is very prolonged and often requires some postoperative management to help the process. In such thick-skinned noses it is even possible that the surgery can make the nose tip more enlarged and amorphous if some postoperative management strategy is not done. Known as a polly beak deformity excessive scar tissue formation is prone to form in the tip and supratip areas in thicker-skinned patients that have a large amount of sebaceous tissue.

Steroid injections is the historic method used to treat nasal tip swelling and has been done for decades. While it can be effective steroids are a double-edged therapy with the potential for adverse long-term soft tissue effects if the dose is too high or the injections are done too frequently.

In the February 2018 issue of the journal Facial Plastic Surgery an article was published entitled ‘Use of 5-Fluorouracil for Management of the Thick-Skinned Nose’. In this paper the authors describe their technique for using 5-FU injections after rhinoplasty. Targeted injections of 5-FU (1mg to 25mg) mixed with a low concentration of Kenalog (triamcinolone) are given in 0.1ml aliquots into the desired nasal areas. They provide these injections anywhere from 1 to 5 injection sessions spaced 1 to 4 weeks apart. Such injections can be given as early as one week after surgery or even years later but their greatest effectiveness is in the first three months after surgery. In a one year series of 31 patients who had 55 5-FU injections the only side effects was pain on injection. No adverse soft tissue effects were seen.

5-FU is a well known chemotherapeutic agent used in the treatment of various cancers of the breasts and gastrointestinal tract. Its main mechanism of action is on fibroblasts.  It has an antimetabolite effect by being incorporated into the cell with impairment on collagen formation. As a result of this effect, 5-FU has been used for years in treating hypertrophic and keloid scars and is believed to work by the inhibition of TGF-beta. It is therefore logical that 5-FU would be applied to scar tissue formation after rhinoplasty as well.

Since it is an off-label use, there is no approved or well studied dosing regimen for post rhinoplasty injections. It is commonly practiced as a combination therapy by diluting the 5-FU with steroids in various combinations per surgeon preference. The role of steroids as a diluent is to decrease the pain of injection and to precent recurrent scarring. Since most noses need more than one single injection I also like to mix in some lidocaine as well and wait a bit after the first injection before doing more.

Dr. Barry Eppley

Indianapolis, Indiana

February 18th, 2018

Technical Strategies – Intraoperative Positioning Guides for Custom Jawline Implants

 

Custom jawline implants offer an unparalleled ability to reshape the entire jawline and the lower face. Combining chin and jaw angle augmentation in a connected fashion can have a powerful effect given the surface area of the lower jaw that it covers. Because of this surface area coverage even small amounts of implant thickness create an external shape change that is more than I would think.

While the appeal of such a lower jaw implant is obvious, it is not a perfect technology. The design process remains subjective since the software can not yet tell us how to design the implant to achieve any patient’s specific desired look. The surgeon must provide that information to the best of his/her ability and hope the implant’s shape and various thicknesses throughout achieve what the patient wants.

In addition to design considerations, just because an implant is custom designed for the face does not mean that its surgical positioning will match exactly how it was designed to fit on the bone. While this is one of the obvious surgical goals, there is always the chance of implant malposition. Custom facial implants are not like Lego blocks, they do not snap fit together. (I wish they did as it would make the surgery a lot easier) The surgeon still has to place a smooth slippery implant on a smooth bone surface under indirect vision.Through small incisions and pockets that are not fully visualized, the surgeon must position the implant. This is a lot harder to do than how the implant design appears on the 3D skeletal model.

In some patients who have had prior osteotomies (sagittal split ramus osteotomy and sliding genioplasty), the indwelling hardware is actually very helpful. The implant can be designed around or over the hardware which serves as an intraoperative guide for its surgical placement as this hardware is always seen through the incisions.

But most patients don’t have these handy intraoperative guides. As a result it is very helpful to incorporate some intraoperative positioning guides on the implant’s design. I do this by making an extended tab of material that goes up to the ascending ramus opposite the 2nd/3rd molar teeth. Since this can easily be seen through the posterior vestibular incision, it provides a guide as to how the posterior and inferior aspects of the angle portion of the implant is positioned in the bone. (since this part of the implant can not be seen)

Once the custom jawline implant is positioned and secured his tab of material can be removed. It is always best to have any implant material as far removed from being directly under the incision as possible.

Dr. Barry Eppley

Indianapolis, Indiana

February 17th, 2018

Case Study – Female Custom Chin Implant

 

Background: Chin implant augmentation is the most commonly performed of all facial implants. The procedure has been done for over fifty years and, as a result, a wide variety of chin implant styles have been developed. While often named after the surgeon who developed them (which is not particularly helpful in understanding what they are intended to do), just about every aspect of every external chin change can be accomplished.

It is important to remember that most chin implants have been developed for the ‘average’ facial bones they augment and are based on anatomical skeletal models. As a result they will not fit everyone’s face well and create the exact intended aesthetic result. This becomes particularly evident in cases where the anatomy is abnormal such as in bony chin asymmetry, vertical chin deficiencies, gender specific needs and when the aesthetic demands are ‘extraordinary’.

Surgeons often try to make standard chin implants work in these non-standard augmentation situations through modification of the implant or in its bony position. And while it may work some of the time, there are many instances when it does not. These aesthetic failures create the need for a custom chin implant approach. And also illustrate why a custom implant approach may have been done initially.

Case Study: This female wanted a chin augmentation that was very specific for her small feminine face. She had existing chin asymmetry with the one side of the chin longer than the other. (or one side shorter than the other?)

Her goal was a chin augmentation result that corrected the asymmetry, kept the chin narrow and provided a forward and slightly vertically longer chin. A custom chin implant was designed to create this specific type of changes. While it was a petite chin implant it had very specific dimensional criteria.

Under general anesthesia and through a submental incision, the chin implant was placed and secured with a single microscrew. Chin implants that have some vertical design to them sit more on the edge of the bone, and even though they are custom made, are best secured with small screw fixation.

Just because the area of chin coverage may be relatively small does not mean that there does need to be an exacting design to it. Like the nose the projection nature of the chin makes its shape erasely apparent and scrutinized.

Highlights:

1)  Not all standard chin implants work well for everyone.

2) The most common reasons a standard chin implant is inadequate is when there is bony chin asymmetry, a need for vertical lengthening, dimensions beyond what standard sizes can do or when extensions are needed far back along the jawline.

3) A custom chin implant is most commonly used when a standard chin implant has ‘failed’, unless the surgeon first recognizes how likely a standard implant can work.

Dr. Barry Eppley

Indianapolis, Indiana

February 17th, 2018

Case Study – Arm Lifts after Weight Loss

Background: Large amounts of weight loss is a very positive benefit to one’s health when needed. But the tradeoff for this medical and often needed benefit is the unaesthetic sequelae of loose skin. How significant this new problem is depends on many factors including the amount of weight loss, patient’s age, natural quality of their skin, gender and the specific body area.

One body area that is hit particularly hard when large amounts of weight loss has occurred is the arms. This is particularly true in women. Stretched out skin and fat fall off of the back the arms and hangs. Often referred to as ‘batwings’, these unflattering segments of loose skin also pose problems for clothing wear in addition to their embarrassing appearance.

Arm lift surgery for ‘bat wings’ has been around for decades and is not new. It has been used for body contouring long before bariatric surgery and other forms of weight loss ha come into widespread use. While contemporary arm lift surgery has undergo some advancements (concomitant use of liposuction, incisional placements and the development smaller versions of it), its fundamental premise is the same. One has to be willing to tradeoff a long scar for a complete upper arm reduction/reshaping.

Case Study: This 65 year-old female has lost some weight but her arms never really changed that much. Rather than  having a batwing deformity that involved the whole upper arm, her worst tissue sag was in the upper half of the arm closer to the armpit.

Under general anesthesia and with the back of her arms suspended vertically using a padded cross table bar, a long horizontal ellipse of posterior arm skin and fat was removed. More was excised closer to the armpit than near the elbow.  The incisions were closed by advancing a posterior fasciocutaneous flap to the anterior skin edge. No drains were used and a subcuticular closure was done.

Like all arm lifts there is going to be a dramatic change in the shape of the upper arm. It would he hard to have that happen when such segments of tissue are removed.

While infections and serums are always possible, the most common adverse sequelae of the procedure is the scar. Quite frankly I have seen very few great arm lift scars, it is just a tough area for that to occur given that the long incision runs perpemdicular to the relaxed skin tensions lines of the arm. The best arm lift scars I have ever seen are those that went on to have a secondary scar revision where the skin edges are closed under much less tension.

Highlights:

1)  The posterior or medial arm lift is the only reshaping procedure of the upper arm when skin removal is needed.

2) Arm lifts are very successful procedures that do definitely solve the sagging upper arm problem.

3) All maximally effective arm lifts involve a longitudinal scar that runs between the  armpit and the elbow whose aesthetic appearance is often not ideal.

Dr. Barry Eppley

Indianapolis, Indiana

February 12th, 2018

Fat Injections, Stem Cells and Injectable Scar Therapies

 

Fat injections have become the modern day equivalent in plastic surgery of the ‘magic bullet’. Like antibiotics over 75 years ago (although not quite that dramatic) fat injections have become widely used for a variety of problems in plastic surgery from treating radiation-damaged tissues to cosmetic augmentations of the face and body. Clinical successes are numerous although the exact reasons why remains speculative and many research studies have been done around the world to provide insight into this question.

The assumption has always been, and there is a lot of evidence to support it, that the stem cells in fat is the secret ingredient. Because it is an autologous treatment and not a synthetically derived drug, this has to its widespread use way before an understanding of how it works has been determined. Fat injections are largely harmless and, as a result, they have been applied to many difficult problems. Scars can certainly be difficult problems particularly recurrent scar formations and pathologic variations thereof. Injecting fat into scarred and contracted wounds has a lot of appeal and clinical successes are widely reported.

In the March 2018 issue of the Annals of Plastic Surgery an article was published entitled ‘Adipose-Derived Tissue in the Treatment of Dermal Fibrosis: Antifibrotic Effects of Adipose-Derived Stem Cells’. In this review paper the authors explore the current scientific understanding of how fat injections may improve hypertrophic scars and other fibrotic skin and subcutaneous issues through various antifibrotic mechanisms. As is commonly believed it is the stem cells, or more specifically stromal cell–derived factors, that exist within the fat which generate its therapeutic effects on difficult scar tissue probolems. Their mechanism of action is primarily done by paracrine signaling. This turns on numerous molecular pathways for an antifibrotic action by modulating the central profibrotic transforming growth factor ?/Smad pathway which normalizes the function of fibroblasts and keratinocytes in the involved area. Other mechanisms are undoubtably involved, some of which are yet to be discovered and studied. But stem cell conversion into new fibroblasts and even adipocytes is one commonly believed effect that results in less scar and softer tissue as well.

Despite its widespread use and substantial clinical evidence of its benefits, the actual mechanisms of fat injections on scarred tissues is far from well understood. While its clinical use has spurned much scientific investigations in the past decade, the need to understand why it works in many different clinical situations ensures that an equal if not greater number of research studies will be done in the future. Such studies will likely lead to a drug-like therapy that provides a controlled effect through dosing and perfected delivery mechanisms. Decades from now what is done with fat grafting and stem cells will make what we are doing today look fairly primitive.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2018

The Contemporary Use of Custom Forehead Implants

 

Augmentation of the forehead is done for a variety for reasons which differ based on gender and ethnicity. In women it is usually to create a rounder and more vertically inclined forehead which often does not include the brow bones. In men it is either for brow bone augmentation alone, correction of a backward forehead inclination or for a combined forehead-brow augmentation effect.

Historically forehead augmentation was done using bone cements. While this method can be effective for some more modest aesthetic forehead improvements, its use requires a full or nearly full coronal scalp incision as well as the need to intraoperaively shape the material. While intraoperative material shaping may seem appealing, it relies entirely on the surgeon’s ability to do so and is more limited for complex shapes particularly if it involves the brow bones.

Custom forehead implants have become the contemporary method for an type of augmentation of the upper facial third. While its solid silicone material can appear to be a disadvantage due to lack of tissue ingrowth/adherence, its many other advantages far outweigh this one biologic ‘disadvantage’. First and foremost, custom forehead implants are made before surgery through the use of computer design. This means that any shape and thickness of the forehead augmentation can be created provided the surgeon believes the overlying scalp/forehead tissue can accommodate it. This is of tremendous relevance when the augmentation involves the brow bones since this area is very hard to adequately augment with bone cements.

The second advantage of custom forehead implants is that they can be placed through a much smaller scalp incision. Because the implant is flexible it can pass through an incision that has less of a length than the widest part of the implant. At the very least the scalp incision does not have to extend beyond the lateral temporal lines…and keeping the incision away from the side of the head (temples) helps tremendously with incision camouflage.

The third advantage of custom forehead implants, which on the surface may not seem so, is that it is easily reversible. Should a revision of the forehead implant be necessary, it can be removed and reinserted in the straightforward manner in which it was inserted.

Most forehead augmentations do not usually need large amounts of augmentation in terms of thickness or forehead expansion. Conversely, however, their shape demands are often very specific and the outline (footprint) of the implant is critical. The surface of the forehead may seem fairly flat but it is more complex than usually perceived and changing that surface into a more desirable outer contour is best done with preoperative computer designing.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2018

Fat Processing Methods for Injectable Facial Fat Grafting

 

Fat grafting to the face has become an accepted and popular soft tissue augmentation method. Most of this fat grafting is done by injection given its versatility and ability to be done just anywhere on the face. By harvesting the fat by liposuction from a body site, it is processed and then injected. Given the highly unpredictable nature of such injected fat graft retention, much debate has been given for the various steps in the process to optimize graft volume retention.

The processing part of the harvested fat has been the most scrutinized part of the facial fat grafting process. Methods available include telfa wecking, gravity separation and centrifugation. Which of these three fat processing techniques methods results in better fat graft survival and volume retention? Lack of any standardization in fat grafting to date makes determining the best fat processing method difficult.

In the January 2018 issue of the JAMA Facial Plastic Surgery journal an original investigation was published entitled Three-Dimensional Volumetric Analysis of 3 Fat-Processing Techniques for Facial Fat Grafting – A Randomized Clinical Trial’. In this paper the authors compared three fat processing techniques with 3-dimensional (3-D) technology to determine the optimal fat-processing technique for improving the volume retention of injected facial fat. Over a one year period over fifty (52) patients with facial asymmetry were treated by facial fat grafting. The patients were equally divided into three groups based on the fat processing method of the injected fat, sedimentation (group 1), centrifugation (group 2), and cotton pad filtration. (group 3) After surgery patients underwent 3-D scanning before and at 1, 3, 6, and 12 months after surgery.

Assessment was done by determine the volume of the graft maintained with 3-D software. The mean (SD) percentage volume maintenance at 1, 3, 6, and 12 months postoperatively was, respectively, 49%, 45%, 43%, and 41% for Group 1cotton pad filtration group; 41% , 38%, 36%, and 34% for Group 2 centrifugation group; and 37%, 34%, 31%, and 31% for Group 3 sedimentation group. Variance analysis showed that the cotton pad filtration group demonstrated a statistically significant higher percentage volume maintenance in comparison with the centrifugation and sedimentation groups.

While the authors and their analysis showed the cotton pad infiltration method of fat processing produced better graft survival, I would take a slightly different take on their findings. At the least this clinical study shows that all three fat processing methods have success and advanced processing technology does not necessarily make for better fat grafting results. Cotton or telfa pads are certainly low tech but they work.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2018

Case Study – Female Submental Chin Reduction

 

Background: Chin reduction remains an infrequently performed and challenging procedure. It is a far ‘simpler’ aesthetic prospect to stretch out the soft tissues of a bony prominence through implants or osteotomies (chin expansion) than it is to do a bony chin reduction. While often believed that simple burring of the bone from an intraoral approach will work, and it does for horizontal bony reduction, it often creates secondary soft tissue issues.

When soft tissues are detached from the bone and the bone support simultaneously reduced, there is a high risk of a subsequent soft tissue sag. This is well chronicled in both chin and cheek reductions. While it would be great if the facial soft tissues always contracted and shrunk down around areas of reduced bone support…this is not always so.

Appreciation of soft tissue sags and redundancies serves as the basis for a submental chin reduction approach. And it also is how soft tissue problems after other chin reduction approaches are managed.

Case Study: This female was bothered by her overprojecting chin. This was present both at rest and when smiling. It was too vertically long and had slightly too much horizontal projection. Its width and current shape was acceptable.

Under general anesthesia and through a submental incision, a 5mm vertical bony chin reduction was initially done. Then a 3mm horizontal bony chin was done. A full-thickness segment of skin, fat and muscle was removed and the soft tissues tightened around the reduced chin bone.

The submental chin reduction technique provides direct visual access for the best 3D bony chin reduction result. It allows the opportunity to do so while staying well below the exit of the mental nerve from the sides of the bone, making the risk of lip numbness negligible. It also allows for the opportunity, and almost always a necessity, to reduce excessive soft tissue and tighten it around the chin bone.

But the submental chin reduction does place a scar under the chin and this is always an aesthetic concern. These scars typically heal well and the incisional appearance is almost never a concern. There may be a need for a secondary submental soft tissue revision as the desire to limit the length of the scar must be balanced against how much soft tissue to remove. during the tuck part of the procedure. This means that occasionally there may be some soft tissue redundancies (dog ears) that appear at the end of the incision only seen after complete healing.

Highlights:

1)  A 3D chin reduction is often done best by a submental approach.

2) With bone reduction often comes the need for soft tissue reduction as well to prevent soft tissue pad sagging or excess.

3) The submental chin reduction incision heals well but soft tissue redundancies at their ends may need to be revised secondarily.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2018

The Anatomic Basis for Custom Infraorbital-Malar Implants

 

The cheeks occupy a prominent aesthetic position in the midface. They create some amount of facial prominence/angularity as they curve around between the eye and the side of the face. While the cheek is often perceived as an isolated circular area by the side of the eye, as is commonly seen in the shape of most standard cheek implants, this is not how this facial area is anatomically constructed.

The cheek or malar region is an aesthetic term of which its bony anatomy is more extensive than the name implies. The zygomatico-maxillary-orbital bone complex is the bony foundation of the cheek. It is not an isolated bony area but a long stretch of bone that runs from the temples posteriorly to the infraorbital rim. This can be appreciated by those people who have or seek the ‘high cheekbone’ look.

It should be not surprise, therefore, that undereye hollows are associated with flatter cheeks as well given that they are part of the same bony region. When treating undereye hollows by implant augmentation it would be very uncommon that infraorbital augmentation is done alone. It is always best done by more of a wraparound implant design that provides a continuous and blended stretch of augmentation which is the anatomic basis for custom infraorbital-malar implants.

Custom infraorbital-malar implants are placed through subciliary lower eyelid incisions. This provides the most direct access for the linear dissection that is needed from the nasal bones medially to the posterior end of the zygomatic arch. It is interesting how long or large such an implant can look when placed on the face compared to how it looks on the bone in a 3D design.

Saddling on the infraorbital rim rather than just sitting in front of the bone is part of the smooth continuous design and is an important design feature than provides the best improvement in undereye hollows. This part of the implant is secured to the infraorbital rim with small microscrews. Assuring a good fit along the infraorbital rim is critical as this determines how the long hidden wings of the implant over the zygomatic body and arch will be positioned.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2018

Case Study – Female Crown of the Skull Augmentation with a Custom Implant`

 

Background: The shape of the head in a female has important aesthetic significance. While the concept of having a ‘nice round head’ is perceived as an ideal head shape, the ideal woman’s head shape is much more of an oblong shape. But the area over the crown of the head is of particular significance as it should be the highest peak of the skull in women. This is quite unlike men who would view such a location of maximal skull height as an unaesthetic protrusion.

Why women like a more prominent crown of the head is not precisely clear. At the least they do not like a crown area that is flatter or lacks projection. It may be its appeal from is influence on how it pushes the hair upward. This is suggested because many women who undergo crown augmentation talk of the tedious nature of teasing their hair to look like they have a higher crown area of the head.

Creating a higher crown of the head can only be done by building up the skull. Between bone cements and implants, these are the only two effective augmentation options. While fat grafting has become popular for injectable soft tissue augmentation, this technique will not work for skull augmentation as the scalp is too tight to be pushed outward by the soft consistency of fat. Custom made implants from the patient’s 3D CT scan has become the most effective technique to ensure the best augmentation shape and the desired area of skull coverage.

Case Study: This young female was bothered by the flat area over the crown of her head. A 3D CT scan showed how her skull shape sloped downward over the crown area as well as a triangular shape from the front view.

From the 3D CT scan a custom implant was designed to cover the crown area and give a more convex shape. The maximum central projection was set at14mms which was felt to be as much as the scalp could stretch in a one-stage implant augmentation.

Under general anesthesia and in the prone position, a 9 cm horizontal zigzag scalp incision was made over the nuchal ridge of the occiput. A subperiosteal pocket was made way up over the crown area. To keep the incision as limited as possible it is necessary to fold the implant for insertion. In thicker skull implants that are 1cm or over in the area of maximal projection, it is helpful to create a tighter implant roll to remove strips of material on its inner surface parallel to the direction of the implant roll.

The implant is then inserted in a rolled fashion and unrolled and positioned once inside the pocket. The compass marker on the implant serves as a key guide for proper implant positioning and midline alignment as this is the only part of the implant seen through the incision.

A custom skull implant is the most assured method for a higher crown area for women, creating the so called ‘bumpit’ effect. The firm composition of the implant provides the best push on the overlying scalp creating a permanent long-term augmentation effect.

Highlights:

1) The flat back or crown of the head is the common location for aesthetic skull augmentation.

2) The maximum thickness of the implant’s central projection and the amount of skull augmentation possible is controlled by how much the scalp can stretch to accommodate it.

3) Custom skull implants provide a ‘bump it’ effect for females.

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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