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Dr. Barry Eppley

Explore the worlds of cosmetic
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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

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

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

January 23rd, 2017

Case Study – Custom Jawline Implant Replacement

 

Background: A more complete jawline augmentation is most commonly done using standard chin and jaw angle implants. With good implant selection and ideal placement on the jawbone, an enhanced and satisfying jawline can be achieved. While numerous options in both silicone and Medpor facial implants exist, the material used is of no biologic or long-term consequence. What matters is the shape and size of the implants used.

While more successful than not, a three implant jawline implant approach is associated with a higher rate of complications than any one single facial implant. With three implants the associated risks of infection, implant malposition and undesired aesthetic effects are…three times higher than that of a single implant. By far, implant malposition (asymmetry) of the jaw angles and undesired aesthetic results make up the vast majority of jawline implant complications and the need for revisional surgery.

When the aesthetic results of standard chin and jaw angle implants are inadequate the most effective approach is to make a new implant using a custom approach. This is particularly relevant if the standard implants were very inadequate for the patient’s desired aesthetic needs.

Before Custom Jawline Implant Dr Barry Eppley IndianapolisMedpor Chin and Jaw Angle Implant Jawline Augmentation Dr Barry Eppley IndianapolisCase Study: This 42 year-old male previously had Medpor chin and jaw angle implants to try and create a more masculine and well defined jawline. While he had no medical complications from his implants and they were placed fairly symmetrically, they did not come close to the desired jawline effect. A custom one-piece wrap around jawline implant was designed from a 3D CT scan and a stone jaw model as a replacement.

Medpor Jaw Implant Removals Dr Barry Eppley IndianapolisCustom Jawline Implant design on model Dr Batrry Eppley IndianapolisUnder general anesthesia, his Medpor chin and jaw angle implants were removed through his existing external submental and intraoral posterior incisions. The jaw angle implants were particularly difficult to remove due to tissue adherence and being wrapped around the bony jaw angles. The implants and their fixation screws were removed in many pieces.

Custom Jawline Implant Replacement of Medpor Implant result front view Dr Barry Eppley IndianapolisCustom Jawline Implant Replacement of Medpor Implants result oblique view Dr Barry Eppley IndianapolisCusytom Jawline Implant Replacement for Medpor Implants result side view Dr Barry Eppley IndianapolisHis new custom jawline implant was inserted and fit perfectly to the bone as designed on the 3D CT scan. His immediate surgery results showed a dramatically different aesthetic outcome from his standard implants with a much more defined jawline appearance.

Highlights:

1) Replacement of inadequate standard chin and jaw angle implants is best done with a custom jawline implant design.

2) Removing Medpor facial implants can be very challenging particularly over the jaw angle region.

3) Placement of a total custom wrap around jawline implant can be done through the same incisions as the original chin and jaw angle implants were placed.

Dr. Barry Eppley

Indianapolis, Indiana

January 22nd, 2017

The LeFort Custom Midface Implant

 

LeFort 1 osteotomyThe LeFort osteotomy is the well known of all facial osteotomies and is used to correct midface retrusion. In its most commonly used form, the  LeFort I osteotomy, it is named after the fracture pattern originally described by Rene LeFort over one hundred years ago in that cuts are made across the maxilla above the tooth roots as well as through the pterygomaxillary junction. Although less commonly performed, higher levels of the LeFort osteotomy (II and III) are used for more complete midface deficiencies that are associated with craniofacial deformities.

Aesthetic midface deficiences are common in certain ethnic faces (e.g., Asian), traumatic midface fractures as well as general developmental patterns in some people. Many of these patients, however, can not be treated by LeFort osteotomies as they have a normal Class I or orthodontically corrected occlusion. Without the simultaneous correction of a malocclusion, the bone can not be brought forward otherwise it would create one. In addition, most aesthetic midface deficiencies do not justify skeletal correction due to the magnitude of the surgery and its associated risks.

Custom Midface Mask Implant Dr Barry Eppley IndianapolisThe custom midface implant offers an effective aesthetic operation that can have much of the same midface augmentation effect as many of the Lefort osteotomies. (minus the potential aesthetic benefit of forward teeth movement on the upper lip) It can cover the anterior face of the maxilla up onto the orbital rims and the cheeks. This can effectively pull the entire midface soft tissues forward including the base of the nose. It appears much like a mask in its design.

Total Custom Midface Implant Dr Barry Eppley IndianapolisThe design of the custom midface implant can done in variable amounts of dimensional changes across the face of the implant. The greatest fullness can be around the base of the nose and anterior nasal spine or it can be the exact opposite where it is thicker over the cheeks and infraorbital rim. It all depends on each patient’s aesthetic facial needs.

The custom midface implant is usually completely inserted from inside the mouth. In some cases where the implant comes ups around the infraorbital rims a lower eyelid incision may be needed to ensure its accurate positioning. The implant is inserted around the infraorbital nerve by making a slit in the implant above the nerve hole so it may safely wrap around it during insertion.

Dr. Barry Eppley

Indianapolis, Indiana

January 22nd, 2017

Anatomic vs Round Silicone Breast Implants

 

Anatomic Breast Implants Dr Barry Eppley IndianapolisAnatomic or tear drop breast implants purportedly offer a more natural breast augmentation result. This seems to make complete sense when one looks at the shape of an anatomic implant where it has a teardrop shape that more closely mimics a natural breast than a round-shaped implant.

In the January 2016 issue of the journal Plastic and Reconstructive Surgery a paper on this topic was published entitled ‘Comparing Round and Anatomically Shaped Implants in Augmentation Mammoplasty: The Experts’ Ability to Differentiate the Type of Implant’. In this paper thirty (30) plastic surgeons and nurses looked at before and after pictures of thirty (30) submuscular silicone breast implants, either round or anatomic shaped) with an average volume of around 300cc (none greater than 340cc) within the first 3 months after surgery. Among the total of 1800 observations done, the observers could only accurately identify the correct implant style 50% of the time.

While previous studies looking at the same breast implant shape issue have shown similar inabilities to identify the type of implant shape used, this is the first one that has done so in a prospective analytical designed fashion. It is well known that the round or convex form of a breast implant will change into an anatomic shape in the standing position due to both the pressure of the overlying pectoral muscle and gravity. It only re-assumes a more rounded shape when laying down just like the implant looks when laying outside the patient on a table.

Anatomic Breast Implants results front view Dr Barry Eppley IndianapolisAnatomic Breast Implants results oblique view Dr Barry Eppley IndianapolisWhile these study results are both solid and I believe accurate, it is important to point out that its relevance is with smaller implant sizes and with them in the subpectoral pocket. Whether similar results would occur in larger breast implant sizes or in the subfascial position is open for debate. It has been my experience that in larger breast implants the effect of an anatomic breast implant is more relevant particularly in the short term. I would also have little doubt that a shaped implant would look more natural in the subfascial location.

When choosing an anatomic breast implant there should be compelling reasons to do so given their higher cost and risk of malrotation and breast shape deformation, a complication that does not exist with round implants.

Dr. Barry Eppley

Indianapolis, Indiana

January 22nd, 2017

OR Snapshots – Perioral Mound Liposuction

 

There are numerous fat compartments on the face that can be surgically reduced. The most recognized and easily removed is the buccal fat pads. (aka buccal lipectomy) Located just under the cheekbones, it is a very discrete collection of fat that has its own pedicled blood supply and a surrounding capsule. It is removed from an intraoral approach through a small incision just opposite the molar teeth.

While the buccal fat is a large collection of fat compared to the rest of the face, it is frequently given more credit that it is due. Its removal affects the fullness of convexity of the cheek just under the cheekbones. It does not extend very low onto the face and its thinning effect will be relegated to the upper cheek area. If you drew a line from the tragus of the ear to the corner of the mouth, a buccal lipectomy has its effect above this line.

Perioral Mound Liposuction markings Dr Barry Eppley IndianapolisBelow this drawn line sits another smaller collection of facial fat known as the perioral fat or, when bulging, the perioral mounds. This is a subcutaneous non-encapsulated fat collection that sits between the skin and the buccinator muscle. It is located at the southern end of the cheeks or its lower half. It has no anatomic connection to the buccal fat pad. In rare cases the buccal fat pad has been known to fall or prolapse into the perioral mound area.

Removal of perioral mound fat is done by very small liposuction cannulas. It is never an impressive amount of fat that is removed but a little fat reduction does make for a visible external effect. It is a good companion to buccal lipectomies for a more complete cheek reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

January 22nd, 2017

Case Study – Male Mouth Rejuvenation

 

Background: Aging affects all areas of the face and is always most observed in the sphinteric areas of the eyes and mouth. The mouth develops very consistent age-related changes including thinning of lip vermilion show, lengthening of the upper lip and a downward slant to the corners of the mouth. It is all part of the overall tissue shrinkage and southern drift that occurs in overall facial aging.

One of the main differences in male vs. female perioral aging is that men develop far less vertical lip wrinkles. The thicker skin of men due to containing hair follicles and the lifelong use of microdermabrasion (shaving) accounts for the far less number and depth of perioral wrinkles.

The other difference between men and women in age-related mouth changes is that men generally tend to care less about them. This, however, does not mean all men do and there is one mouth change that even most men will eventually dislike…the downturning of the mouth corners.

Case Study: This 68 year-old male was bothered by his mouth appearance. He felt his upper lip was too long and he particularly disliked his mouth frowns. He felt that people viewed him as being angry and unpleasant…when he was not really that way. He felt that people saw him as unapproachable and unfriendly because is mouth at rest had a frown.

Male Subnasal Lip Lift and Corner of the Mouth Lifts drawings Dr Barry Eppley IndianapolisUnder local anesthesia, a subnasal lip lift was initially performed. His upper lip length along the philtral columns was 20mms. This was reduced by 6mms to 14mmw, a more normal upper lip length. Corner of the mouth lifts were performed using the pennant technique. An 8mm lift was done with skin excision and orbicularis muscle plication. This also had about 2 to 3mms of a  mouth widening effect at each corner.

Male Subnasal and Corner of Mouth Lifts immediate result Dr Barry Eppley IndianapolisMale Subnasal Lip Lift and Corner of the Mouth Lifts immediate result Dr Barry Epley IndianapolisThe thicker beard skin of men makes lip lifts and corner of mouth lifts more favorable in their scar formation than women. Such perioral rejuvenation procedures can work well for men as long as they are not overdone. (over lifted) The other potential adverse scar formation is that with corner of the mouth lifts…but this potential revisional issue is the same for both men and women.

Highlights:

1) Aging of the male mouth consists of upper lip lengthening, thinning of the upper lip vermilion and downturning of the mouth corners.

2) A subnasal lip lift in a male rejuvenates the lip-nose relationship and is an important part of many male mouth rejuvenation efforts.

3) A corner of the mouth lift in a males strives to achieve a neutral or unfrowning mouth appearance.

Dr. Barry Eppley

Indianapolis, Indiana

January 22nd, 2017

Case Study – Occipital Scalp Roll Excision

 

Background:  The scalp is a remarkably thick and well vascularized tissue as it covers the entire skull surface. Its thickness, however, varies at different areas of the skull. It is the thickest on the back of the head where it blends into the posterior neck tissues. The base of the occipital skull also ends up much higher than one thinks, leading to a thick collection of tissue over the back of the head without any underlying bone support.

Scalp rolls on the back of the head appear to occur due for a variety of reasons. Naturally thick scalp and neck tissues, excessive scalp laxity, short necks and being overweight can all contribute to a bunching up of scalp soft tissues in this area. Scalp rolls can appear as a single, double and even a triple roll. The most common presentation is a double roll with deep horizontal skin crease between them.

Skin rolls on the back of the head is an almost exclusive male aesthetic concern. Shaved heads and very closely cropped hair make them visible and can be a source of embarrassment.

Occipital Scalp Roll Reduction drawings Dr Barry Eppley IndianapolisCase Study: This 28 year-old male had a thick neck with two very prominent scalp rolls with an intervening skin crease with his head in neutral position. It turned into a triple roll when he extended his head backwards. Presurgical markings were made of a elliptical excision incorporating portions of the upper and lower skin rolls with the skin crease at its horizontal middle.

Occipital Scalp Roll Reduction incisionks Dr Barry Eppley IndianapolisOccipital Scalp Roll Reduction Excision Dr Barry Eppley Indianapolis copyUnder general anesthesia and in the prone position, an elliptical excision of scalp skin and a wedge of tissue was removed. The periosteum and some soft tissue was maintained on the bone for subsequent placement of quilting sutures at closure. The upper and lower skin flaps were undermined to release some of the additional skin rolls. Closure was done with quilting sutures to close the deep space as well as up to the skin level where a subcuticular closure was placed.

Occipital Scalp Roll Reduction Immediate result Dr Barry Eppley IndianapolisThis excisional and undermining method will remove most of the skin rolls and create a smoother back of the head contour. While it does create a fine line scar, it appears similar to the horizontal skin crease that already existed.

Highlights:

1) Occipital scalp rolls can have multiple presentations from one to three rolls on the back of the head.

2) Excision of a wedge of skin and deeper tissues allows for scalp roll reduction.

3) Widely undermining the scalp flaps above and below the excised tissues helps to work out adjoining rolls as well.

Dr. Barry Eppley

Indianapolis, Indiana

January 21st, 2017

OR Snapshots – Two-Piece Custom Skull Implant

 

Skull reshaping using implants is the only effective method for augmenting head shape. While certain bone and muscle removals can be done for more limited skull reductions, skull augmentations can produce much more dramatic changes. In essence, the stretch of the scalp is far more permissive than the thickness of the skull bones.

In very large skull augmentations the scalp can become a limiting factor and may require a first-stage scalp expansion. But beyond the ability of the scalp to accommodate a large skull implant, getting the proper shape and dimensions of the implanted material is the other major challenge. This is overcome today using a custom design approach with a 3D CT scan. Custom skull implants can now be made to cover any area of the skull including the entire bony skull if desired. (forehead back to occiput)

Two Piece Custom Skull Implant Dr Barry Eppley IndianapolisManufacturing very large or total custom skull implants is difficult because they can cover more than a 180 degree arc with thin edges. To avoid manufacturing problems, a two-piece approach to the implant’s fabrication and insertion can be done. Creating two interlocking edges allows for a two-piece custom skull implant to be accurately reassembled on the patient’s skull the way it was designed.

Very large skull implants are most accurately placed using a long scalp incision. This patient shown here already had a full coronal incision so its total length was used. If such a long scar was not already present, a shorter incisional length could be used.

Dr. Barry Eppley

Indianapolis, Indiana

January 21st, 2017

Aesthetic Vertical Orbital Dystopia Correction Strategies

 

orbital dystopia_edited-2Vertical orbital dystopia is a frequent feature of many facial asymmetry patients. When facial asymmetry affects the midface region most of the time some form of globe dystopia will be present. It is perceived most easily by the difference in the horizontal level of the pupils.

Orbital dystopia is always most clearly seen in pictures as the eyes look ‘off’. This is where patients will notice it the most as well as when looking directly in the mirror. (or in selfies)  There will be one good eye and the affected eye will usually be sitting lower. It is rare that the affected eye is the higher one. For unknown reasons in my experience vertical orbital dystopia occurs much more frequently in the right eye.

The most important step when the eyes appear at different levels is to make the proper diagnosis. This will require a 3D CT scan of the entire face and not just the orbits. Aesthetic (non-craniofacial) orbital dystopia usually has other facial asymmetries as well particularly of the superior brow bone and the inferior cheeks. The entire orbital skeletal box is lower. As a result, the eyebrow and brow bone will also be lower, the upper eyelid may have some mild ptosis and the cheek will be flatter and asymmetric.

Hydroxyapatite Cement Orbital Floor Reconstruction Dr Barry Eppley IndianapolisMild cases (2 to 5mms) of vertical orbital dystopia can be treated by numerous extracranial techniques. Augmentation of the anterior orbital floor (and in some cases the inferior orbital rim), a brow lift and cheek augmentation are the three main skeletal techniques. While numerous implant materials can be used for the orbital bone, including autologous bone grafts, I find the use of hydroxyapatite cement (HA cement) to be very effective. It is easy to apply and shape to the orbital floor and up over the inferior orbital rim if needed.

Orbital Floor Lowering Dr Barry Eppley IndianapolisIn uncommon cases an adjunctive strategy can be to lower the opposite eye as well. If the affected eye can not be adequately raise due to the amount of horizontal pupillary disccrepancy (4mms or greater) the opposite eye can be slightly lowered. This is done by removing part of the bone on the anterior orbital floor. Short of a full orbital decompression, the goal is to achieve a 1 to 2mm lowering of the globe. This dual approach raises the lower eye and very slightly lowers the opposite eye.

In the correction of vertical orbital dystopia, it is also important to be aware of what may happen to the upper eyelid-globe relationship. In most cases of congenital orbital dystopia the upper eyelid follows the eye to maintain a normal appearing upper eyelid to globe relationship. But as the lower eye is surgically lifted, the eye can be come more buried under the upper eyelid. Ptosis repair may be needed to get the eyelid back up higher on the iris.

Dr. Barry Eppley

Indianapolis, Indiana

January 20th, 2017

Case Study – Total Jawline Enhancement with Custom Implant

 

Background:  The approach to improving the shape of the lower face has evolved beyond just chin augmentation. While the projection of the chin still has a valuable role to play in lower facial reshaping, it is not a comprehensive approach to lower facial aesthetics. The shape and size of the entire jawline must be considered.

The single most effective complete jawline augmentation method is by using a custom jawline implant design. While it is made from a 3D CT scan and fits the bone as designed, its effect comes from expanding the entire bony borders of the lower jaw.  Because it covers a broad surface area, its effect can range from a subtle to a dramatic type of facial change.

In some male (and most female) jawline augmentations the patient is seeking a more conservative change. This means that one wants the jawline to be sharper and more angular with modest chin and jaw angle size changes. This is the classic definition of a jawline enhancement as opposed to a major jawline augmentation. To do so the custom jawline implant is often smaller with thin connections between the chin and jaw angles.

male custom jawline implant design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male wanted a stronger jawline but one that was not ‘too big’. He always wore a closely trimmed beard which helped to create the appearance of  stronger jawline. He stated that he would continue to have such a beard after and this had to be factored into the implant’s design and size.

male custom jawline implant design and actual implant Dr Barry Eppley IndianapolisUnder general anesthesia and through a three incisional method (extraoral submental chin and intraoral vestibular incisions), a custom jawline implant was placed. To prevent mental nerve injury it was placed in a midline split two-piece fashion.

Custom Jawline Implant results oblioque view Dr Barry Eppley IndianapolisCustom Jawline Implant result side view Dr Barry Eppley IndianapolisHis after surgery results show a subtle but evident change in the appearance of his lower face. Increased chin prominence was evident as was a more defined jawline heading back to the jaw angles on both sides.

Custom Jawline Implant result front view Dr Barry Eppley IndianapolisTotal jawline enhancement can be done using a custom jawline implant. Keeping the projections at the chin and jaw angle areas more modest with thin connections between these three jawline points can keep the jawline augmentation effect more limited and create a more angular jawline.

Highlights:

1) A custom jawline implant affects the entire jawline in a wrap around implant fabrication.

2) Creating three points of augmentation (chin and jaw angles) that are connected can have a powerful effect on the shape of the lower face.

3) A small custom jaw implant provides an increased angularity to the lower face witout making it too big.

Dr. Barry Eppley

Indianapolis, Indiana

January 17th, 2017

Shoulder Groove Fat Grafting in Breast Reduction Surgery

 

Breast reduction is a combination reconstructive and aesthetic body contouring procedure. It relieves the musculoskeletal symptoms from large hanging breasts as well as lifts and reshapes it higher up on the chest wall. While it does so a the expense of anchor-pattern scars of some length, it is a tremendously effective operation for the large breasted woman.

One of the classic physical signs of breasts that are too heavy for one’s body frame is the presence of shoulder grooves. These occur from the compression of the bra straps on the skin from the weight of the breasts in a bra. Shoulder grooves occur partially from fat atrophy from the constant compression of the bra straps compressing it down on the muscle. They can occur as quite striking and deep on some patients, particularly those with very large breasts.

An interesting question is whether shoulder grooves resolve/go away after a breast reduction. In theory they should go away as the weight of the breasts is relieved on the supporting bra straps. There are, however, no studies which have ever evaluated the resolution of these after breast reduction surgery. Since their presence partly occurs from fat atrophy one could presume that they will persist even after a successful reduction and lift of the breasts.

Fat Grafting Shoulder Grooves at time of Breast Reduction Dr Barry Eppley IndianapolisA treatment for shoulder grooving at the time of breast reduction surgery is fat grafting. Fat harvested from the abdomen can be used to inject into the shoulder grooves. These are beneficial in the deepest of shoulder grooves. It usually takes 20cc to 30cc of concentrated fat into each shoulder groove.

Fat Grafting Shoulder Grooves Breast Reduction Dr Barry Eppley IndianapolisInitial fat take is fairly good and many will show good persistence out at six months after surgery. While the pressure of a bra strap is never completely negated and is certainly not a favorable feature for fat graft persistence, it does not appear to have a completely adverse effect on fat grafting to the shoulder grooves.

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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