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.

July 19th, 2017

Case Study – Custom Forehead-Temporal Implant Replacement

 

Background: The size of the forehead has a major influence on the appearance of one’s face, occupying the entire upper third of it. Beyond its size the shape of the forehead is also important with many gender specific features. In general, males have stronger brows, a wider forehead and a gentle backward slope to it. In contrast female have no brow bone protrusion, a convex forehead shape that has a more vertical orientation.

\Of all the facial bones, the forehead is the least commonly augmented. Intraoperatively shaped bone cements and preoperatively shaped custom implants are the two most common methods of forehead augmentation. Given the advantages of a more thought out forehead shape design and the ability to place it through a small scalp incision, custom forehead implants are usually the superior treatment approach.

But the success of a custom forehead implants comes down to its design. While computer designing an implant has many advantages, what the best shape and dimensions are that can create the patient’s desired forehead shape  is not a mathematical calculation. It is an art form that is based on the surgeon’s understanding of the patient’s desires and experience in appreciating the effects of various designs on the outward aesthetic outcome.

Case Study: This 25 year-old male had a custom PMMA forehead implant placed through a full coronal scalp incision six months previously. While the implant provided some brow bone augmentative effect, it did not extend all the way top the forehead and created a line of demarcation at the mid-forehead level. He was interested in having an implant design that covered his entire forehead as well as extended outward further into the temporal areas.

A new custom forehead-temporal implant design was made that covered more than 100% greater surface area than his indwelling implant. It covered the entire forehead back behind the frontal hairline, extended over the entire anterior temporal region down to the zygomatic arches as well as added a few more millimeters of brow bone augmentation.

Under general anesthesia, his existing coronal incision was re-opened and his forehead implant exposed and removed. The difference in surface area coverage between the removed and new custom forehead-temporal implant was significant.

The new style of custom forehead implant was then inserted and secured with small microscrews to the bone and sutures of the temporal extensions to the temporal fascia.

When designing a forehead implant there are four surface areas or zones to consider. They are the brow bones, the mid- and upper forehead, the temporal lines and the temporal zones. (often referred to as the sides of the forehead) The coverage or lack oil coverage of these areas must first be considered before determining what thicknesses they should be.

Highlights:

  1. Subtotal forehead implants often leave the forehead inadequately augmented.
  2. Custom forehead implants must consider the impact on the entire forehead as well as the adding temporal regions.
  3. Complete frontal augmentation covers the entire forehead as well as the temporal areas.

Dr. Barry Eppley

Indianapolis, Indiana

July 17th, 2017

Case Study – Lower Lip Advancement for Subtotal Hemangioma Excision

 

Background: The lips are composed of both wet and dry tissue known as vermilion. Known as the pink or red part of the lips its presence and size determines whether the size of the lips is interpreted.

But the one red tissue one does not want on their lips is a hemangioma. Hemangiomas are benign blood vessel tumors that develop in the first few months of life. They can grow rapidly, appear bright red and distort the tissues wherein they lie. Once they reach their maximum size they remain stable in size and then undergo a phase of involution. (shrinking) Many hemangioma will almost completely go away but in their wake they often leave distorted skin which is stretched and discolored.

Hemangiomas often occur on the lips and can involve both the lip proper (vermilion) and the adjacent skin. Removing the sequelae of a hemangioma around the lips can be tricky since you do not want to distort the lips in the process of removing any mottled skin.

Case Study: This 40 year-old female had a hemangioma that involved the lower lip as a child. While most of the hemangioma shrunk down there always remained distortion of the lower lip from damaged tissues. Because of the discoloration and tissue distortions the upper lip always looked  somewhat bigger than the lower lip. (more vermilion exposure) Most of the tissue distortions were beyond the vermilion-cutaneous margins into the skin below the lip.

The natural vermilion edge of the lower lip was marked and two options for excision were planned. (subtotal vs complete) It could be seen that complete excision of the abnormal tissues would create too big of a lower lip with the resultant lower lip advancement. A line that removed 50% of the distorted skin was chosen. Under local anesthesia, a strip of lower lip skin was removed and the vermilion edge of the lower lip brought out to close it.

A vermilion or lower lip advancement is typically an aesthetic procedure to make the lips look bigger. (more vermilion exposure) But in tumor resections it can be used to improve lip symmetry and size even if it does not result in complete removal of all abnormal tissue.

Highlights:

  1. While hemangiomas shrink in most children, they often leave behind redundant discolored skin.
  2. In removing residual hemangioma from the lip and lip margin, a vermilion advancement can achieve a subtotal reduction of it and improved upper and lower lip symmetry.
  3. Lip advancements, regardless of why they are performed, should not be overdone since they are irreversible.

Dr. Barry Eppley

Indianapolis, Indiana

July 16th, 2017

OR Snapshots – Extended Arch Cheek Implants Replacement

 

Cheek implants can be the most difficult to decide preoperatively as to their style and size. Because the cheek is an oblique structure and not a profile one, it defies any exact measured target to achieve. The cheek does have very specific zones of augmentation, four to be exact, and it becomes important to consider these cheek zones when selecting the implant style that can achieve the patient’s desired midface look.

Most cheek implant styles focus on augmenting either the malar body and/or the submalar region underneath it. These are the central zones of the cheek. While effective for some patients, they are prone to creating a bulge or bump effect particularly if the size of the implant is too big. This is because the cheek, also known as the ZMC (zygomatico-maxillary) complex, is a bony structure that has three visible legs or extensions to it that emanate out from its main body. To look more natural many cheek implants should flow into these extensions more fully.

One newer cheek implant option is the malar-arch style. As the name implies it is a midface implant that augments the malar body but has a long posterior tail to it that goes back along the zygomatic arch. It extends back along the curved arch and stops before it reaches its temporal attachment. This provides a gentle sweeping augmentation across the cheek area and achieves a more complete and natural cheek enhancement. It is also the type of cheek look seen in many models, for example, whether that is their natural look or has been created by makeup or photo editing.

It has not uncommon that I see a ‘standard’ cheek implant patient who is dissatisfied with just augmentation of the malar-submalar cheek area. Exchanging these standard implants for an extended arch style usually provides a more desired midface enhancement effect. It is the creation of a more horizontal line across the side of the face that is often sought out today.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2017

Case Study – Mushroom Male Nipple Reduction

 

Background: The existence of the nipples in a male is from its embryological development. Since all embryos start out as a female, the existence of the milk lines and the nipples develop before the embryo’s sex has been determined. Once the Y chromosome and testosterone levels make it into a male, the nipples are already present. While female nipples go on to become functional, male nipples are vestigial. Men may look peculiar without them but they have no functional purpose.

The nipples in men are usually taken for granted unless they develop a tissue problem. One of these tissue problems is hypertrophy of the nipple. A protruding or elongated nipple is annoying to most men. It may rub on shirts and get irritated due to tissue chafing. They may also be evident in shirts and be a source of embarrassment. Often both nipple problems occur together.

The diagnosis of an elongated nipple must be differentiated from areolar protrusion or areolar gynecomastia. An isolated elongated nipple has a flat arealar and chest contour around it. Areolar gynecomastia  is when the entire areola is enlarged or puffy. It may or may not have an elongated nipple associated with it.

Case Study: This 35 year-old male was bothered by his elongated nipples which were a source of embarrassment. He had an otherwise flat chest profile.

Under local anesthesia, the nipples were elliptically excised around their base and a core of underlying ductal tissue taken with it. To achieve a completely flat areola, some of the deeper tissue must be taken. The removed nipples resembled a mushroom on their shape. The inner areolar margins were closed with dissolvable sutures.

For most men nipple reduction should really be called nipple removal. While the nipple has a different color and contour to the areola, most men with protruding nipples do not care if any nipple is left at all. The main goal is the assurance that any nipple protrusion is completely eliminated. The mushroom nipple reduction technique assures that a completely flat areolar contour is obtained.

Highlights:

  1. Protruding nipples in a male is often both a source of irritation and embarrassment.
  2. Male nipple reduction usually consists of complete nipple removal.
  3. The mushroom make nipple reduction ensures that the external protruding nipple and the underlying ducts are removed to ensure a complete flat profile.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2017

OR Snapshots – Facial Cyst Removal

 

Lumps and bumps of the face are common. They are usually located in the subcutaneous layer right beneath the skin and, in some types, are directly attached to the underside of the skin. The most common pathologies are sebaceous cyst, dermoid cyst and lipoma. While they are benign they will usually continue to grow. While initially felt as a small non-visible lump, they often create an external distortion as they grow.

Facial cysts are mostly a cosmetic concern provided they do not get infected. (dermoid cysts and sebaceous cysts can, lipomas will not) While they can be quite disconcerting when they are found and they often continue to grow slowly, they can be removed in most cases with minimal scarring if done properly. Unsightly scars can make the facial area look worse in appearance than the original pathology.

While placing the incision in a skin crease away from the facial lesion site has the advantages of a more hidden scar, this is not always possible to do. The commonly used method is with a small skin incision directly over the lump. This also has the advantage in dermoid cysts that the attached skin pore is also completely removed to avoid cyst recurrence. In most cases the incision will need to be almost as long as the mass to ensure that its walls and contents are completely removed. These can be done under local anesthesia in the office in teens and adults. Infants and children will require an anesthetic to perform it.

As long as the incision is placed parallel to the relaxed skin tension lines of the face, even though it is in an exposed area, the scarring will be quite acceptable. Skin closure of these facial lesions excisions is often done in a subcuticular technique so no sutures need to be removed and no suture track marks all be left behind.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2017

Technical Strategies – Rib Graft Shaping in Rhinoplasty

 

Rib grafts are the material of choice for many larger augmentative rhinoplasties and complex nasal revisions. They offer a virtually unlimited amount of cartilage graft material that can be used anywhere on the nose from the bridge down to the tip and columella. Because cartilage is softer than bone and relatively easy to carve, it is a versatile graft material that can be shaped for a wide variety of nasal reconstructive needs.

Besides the need for a donor site, the other downside to a rib graft is that it is rarely completely straight. Much of the shape of the ribs is largely curved as it bends around the side of the chest to join into the sternum. When harvesting cartilage the surgeon tries to take the straightest piece possible but, more times than not, a sizable rib graft harvest is likely to have a bit of a curve to it. Thus some form of graft manipulation/reshaping is needed.

The most common form of rib graft reshaping is to carve it like one would a bar of soap. A scalpel is use to carve it into the desired graft shape. In doing so it is well recognized to be aware of the bend of the rib and the attachments of the perichondrium. Since the perichondrium exerts a pulling force on the surface of the rib, it is important to keep the perichondrium attached on the convex side away from the curve and to remove the perichondrium and cartilage on the concave side of the curve.

Another useful or additive technique is to score the cartilage on the opposite side of the curve even though the perichondrium is left intact. Then multjple through and through sutures are placed to bend it straight or to ensure that it stays straight. This can work well in slight bends and if one is concerned about postoperative warping. Usually two to four transverse scores are needed for a long dorsal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2017

Case Study – Fibro-Osseous Occipital Knob Reduction

 

Background: The back of the head is usually a smooth convex shape. While the amount of convexity will vary amongst different people, protrusions on its outer surface are not usually seen as aesthetically desirable. Thus the discrete occipital knob deformity stands out.

The occipital knob deformity is a well known central bony protrusion just above the bottom of the occipital bone. It sticks out like the knob in its name. It is most typically composed of a large growth of bone that develops centrally at the nuchal ridge line. It is a thicker than normal protrusion of bone which when reduced solves the occipital contour concern.

The occipital knob skull deformity is also known as the occipital bun or occipital horn. It is well known to occur in Neanderthal skulls but much less commonly so in modern man. Why it occurs is not known but it is always thought of as a pure bone excess. But in its aesthetic reduction the overlying soft tissue must be considered as well.

Case Study: This 35 year-old male was bothered by the bump on the back of his heads. It was also associated with a thick overlying scalp and a horizontal skin crease both above and below the bump.

Under general anesthesia and in the prone position, the occipital knob reduction was approached through the lower skin crease in non-hair bearing neck skin. The bony bump was identified and reduced down to the surrounding skull bone with a handpiece and burr. Surprisingly the size of the occipital knob was less than its outward appearance would suggest. There was a very thick fibrofatty tissue layer between the skin and the bone which was excised and thinned out. Redundant overlying scalp was also excised.  A small drain was then placed and the wound was closed in layers.

His immediate intraoperative results showed a significant flattening effect to a more normal contour. In this case such a reduction would not have been possible without concurrent soft tissue thinning as well. It appears that in some occipital knobs the overlying scalp becomes thicker than normal, much like that which has occurred with the underlying bone.

Highlights:

  1. The occipital knob deformity is not always a pure bony deformity.
  2. Some occipital knobs have a significant soft tissue component that must also be removed to optimize the flattening effect.
  3. The lowest horizontal skin crease should be used to reduce this type of occipital knob.

Dr. Barry Eppley

Indianapolis, Indiana

July 12th, 2017

Case Study – Sagittal Crest Head Reshaping

 

Background: There are many different varieties of aesthetic skull shape issues in the adult. While most are from congenital issues related to head molding and are more ‘minor’ in the severity of their expression, some are from variations of true skull pathologies known as crniosynostosis. This is where the sutures that exist between the plates of skull bone during early infancy come together or fuse too early. Such sutural fusions or synostoses create well described head shape abnormalities that are treated in early infancy by bone removal and reshaping. (cranial vault surgery)

But some of these cranial suture abnormalities do not occur completely and do not present with the full blown head shape deformity. Rather they have an incomplete presentation with less severity that was either undiagnosed as a child or was felt to not warrant early aggressive skull reshaping surgery. These are sometimes called microform deformities or, as would be called in urban terms, an odd-looking or unusual head shape.

One of these microform head shapes is that of the adult sagittal crest skull deformity. A variant or  incomplete expression of sagittal suture craniosynotosis, it presents as various types of peaked skull shapes. There is a high or raised bony midline front to back (the crest is always higher in the back) and a relative parasagittal or parallel bony deficiency to the sides. This gives the top of the head various degrees or angles to their head shape when viewed from the front.

Case Study: This 45 year-old male had always been bothered by the shape of his head since he was young. He has a peaked skull shape that was high in the middle and sloped down to the sides. It was also flatter in the back. A 3D CT scan showed that his head was so shaped as a direct result of how it skull had developed.

A surgical plan was devised to improve his head shape through a combination of sagittal crest bony reduction combined with a custom made skull implant that wrapped around three-quarters of his head, filling in the bony deficiencies. The combination of skull reduction and skull augmentation was designed to give him a more rounded and less high skull shape.

Under general anesthesia, his existing curved sagittal midline incision was used to access the procedures. (this was present due to a prior scalp reduction procedure. A 4mm sagittal bone reduction was done with a burring technique to make it flatter. Then the custom skull implant was inserted, positioned and screwed into position

Three months after surgery he had a significant change in his head shape with the elimination of the peaked shape to a more normal rounder shape. While some sagittal height was reduced, it was the augmentation that created the vast majority of the positive head shape change.

Highlights:

  1. More severe adult sagittal crest deformities can not be treated by sagittal crest burring reduction alone.
  2. Parasagittal and occipital augmentation using a custom skull implant is needed to correct the bony deficiencies in the mature sagittal crest skull deformity. (sagittal skull reshaping)
  3. A midline sagittal incision can be used to for access to sagittal skull deformities.

Dr. Barry Eppley

Indianapolis, Indiana

July 12th, 2017

PRP (Platelet-Rich Plasma) Injections for Eyebrows

 

The shape of eyebrows in women has changed over the years. While eyebrows used to be desired to be thinner, the fuller eyebrow is more popular today. The first step to fuller eyebrows is to stop the tweezing and waxing which thins out the hair follicles and slows down their growth. Various serums or topical products have also been touted that promote faster regrowth including topical Minoxidil (Rogaine) and Latisse. (bimatoprost) Both of these pharmacologic drugs have a proven track history of scalp hair and eyelash growth enhancement so it is not a stretch to see how it could work on eyebrow hairs.

An additional treatment option is an injectable serum or agent to help eyebrow hair regrowth is that of platelet-rich plasma. (PRP) PRP is an extract of the patient’s own blood that creates a few milliliters of a platelet concentrate with high levels of growth factors. This is created by a simple blood draw in the office which is then subjected to a centrifuge spin to create the PRP injection. The platelet and growth factor mixture is then injected into the eyebrows. Given that the eyebrows have a small surface area, the dose of PRP its quite high.

PRP eyebrow injections work best in patients with more acute episodes of eyebrow hair growth reduction as well as in younger patients. It will not give fuller brows in someone who has never had them. In short, you can’t stimulate hair to grow from follicles that never existed. But it can induce follicles to resume hair growth or make its current growth faster and fuller. In general, properly selected patients can expect to see a 25% to 30% improvement with each injection session. Injections treatments are usually done every eight to twelve weeks.

PRP injections are also a great adjunctive therapy with eyebrow hair transplantation. Injected one month before and after the procedure, the optimal take and growth initiation of the transplanted follicles is ensured.

Dr. Barry Eppley

Indianapolis, Indiana

July 10th, 2017

Managing the Soft Tissue Triangle in Rhinoplasty

 

Rhinoplasty is most commonly done today through an open approach. The wide exposure offered through the devolving of the nose offers many advantages, particularly in complex and revision noses. But there is a ‘price’ to pay for such open exposure and is not primarily the scar that it creates. (usually the transcolumellar scar truly heals in an inconspicuous manner.

Notching of the alar rim, or asymmetry of the nostrils, is not an uncommon adverse sequeale from an open rhinoplasty. Such notching or asymmetries occur most commonly in the soft triangle area of the alar rim. The soft triangle is the one area along the top of the nostril between the tip and the nasal base that does not have cartilage support. Since the open approach causing scarring and also requires incisional closure across this area of the nostril which inherently is a bit concave, notching deformities of the alar rim can occur.

In the July 2017 issue of the journal Plastic and Reconstructive Surgery, an article in this topic was published entitled ‘Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty’. In this paper the authors review the anatomy of this small area of the nose, the common causes of alar notching in rhinoplasty and methods for its prevention and correction.Prevention is done initially by placing the margin rim incision far enough back from the alar rim during the opening of the nose. This is harder to do than placing it closer to the rim but is worth the extra effort. During closure of the rhinoplasty elimination of the dead space can be done with soft tissue grafts tucked behind the incision line. If one seems any slight nostril asymmetry or suspects that alar notching will happen, cartilage grafts can be placed into the soft triangle area. (alar contour or alar rim grafts)

Secondary correction of alar notching always involves cartilage grafts. The question is whether cartilage grafts alone or a combined cartilage-skin (chondrocutaneous) graft is needed. An alternative approach is to also use injectable fillers. While it may temporary in many cases, repeated injections can result in more sustained results int some patients.

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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