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 25th, 2016

Case Study – Chin Implant Revision

 

Background: The most common facial augmentation procedure is the chin implant. It has been done for over fifty years with the silicone implant as the most common device used for most of this time. It is often combined with a rhinoplasty but can also be done along or in conjunction with anti-aging procedures like a facelift or other face and jawline procedures like jaw angle implants.

Chin implant designs have evolved over the years with the standard style now used being an extended or anatomic shape. These longer wings that go back along the jawline from the central area of projection allow a smoother transition into the jawline without an obvious ‘bump’ sitting on the chin. This creates a more natural chin augmentation result.

But these extended wings on a chin implant have some potential disadvantages as well. They require a longer dissection along the jawline for the wings to fit. And great attention has to be paid to their symmetrical pocket development and placement. A slight degree of tilt to the implant can have the back end of the wings more significantly displaced up or down. In fact the number one complication of such chin implants today is wing asymmetry.

Chin Implant Malposition Dr Barry Eppley IndianapolisCase Study: This 60 year-old female had a prior history of a chin implant placed several years ago. She developed problems with chin asymmetry, a bulge in the right intraoral mandibular vestibule at the gumline and stiffness in moving the lower lip which also had some asymmetry.

Chin Implant Revision with Screw Fixation Dr Barry Eppley IndianapolisUnder general anesthesia through her existing submental scar, the chin implant pocket was opened and the implant removed. The implant had its right high up on the right side and low on the left side creating  a clockwise tilt. The right implant pocket was opened up and lowered while the left implant pocket was opened and raised. The wings on the implant were shortened 7mms per side and placed in the midline and secured with a single 2.0 x 10mm screw. Closure was done in three layers.

Chin Implant Revision Surgery results Dr Barry Eppley IndianapolisThe improvement in the appearance of the chin became evident as the swelling subsided over the first postoperative month. The chin was more symmetric as was the lip. The lip also moved more naturally. The chin will take several months to feel more soft and to have normal mentalis muscle function. There may also be some chin pad indentations develops as the part of the implant pocket that is no longer used needs to shrink back down to the bone. These chin pad soft tissue irregularities should eventually subside.

Many chin implant revision cases s are due to an asymmetry caused by a tilt of the implant (yaw) or a side to side shift. While the best way to prevent this from occurring is to secure it firmly when initially placed, this becomes doubly important when repositioning the implant during a chin implant revision.

Highlights:

1) Extended style chin implants can develop asymmetry by malposition of their long wings.

2) Repositioning an asymmetric chin implant (chin implant revision) is best stabilized by screw fixation in its new position to prevent relapse.

3) The extended chin implant can have its wings shortened if that is aesthetically advantageous at the time of repositioning.

Dr. Barry Eppley

Indianapolis, Indiana

July 25th, 2016

Cheekbone Reduction and Facelift Surgery

 

Cheekbone reduction is a common facial skeletal procedure done for aesthetic purposes in Asians. It is not done exclusively in Asians, as many different ethnic groups can have wide cheeks, but the vast majority are.

One of the main risks of cheekbone reduction is sagging of the attached soft tissues. This can be avoided by how the osteotomy is done and with good bone fixation. But in older patients who are already predisposed to loose cheek tissues this risk becomes magnified. It has been suggested that the risk cheek sagging can be prevented by combining a facelift procedure with cheekbone reduction in older patients. This can help create an oval and youthful midface.

In the August 2016 issue of the Annals of Plastic Surgery an article was published entitled ‘Reduction Malarplasty With Face-Lift for Older Asians With Prominent Zygoma’. In this clinical series over 20 older Asian women had a combined cheekbone reduction facelift procedures for their prominent zygomas and aging faces. The cheekbone reduction was done using an L-shaped osteotomy pattern. The facelift was performed in a usual fashion. All of the patients recover successfully with any major complications. The prominence of the cheekbone and sagging midface tissues were improved and the natural midface contour was preserved. Near one hundred percent satisfaction with the improved midface shape as well as rejuvenation of midface was achieved.

The most important aspect of this paper to me is that the performance of a facial skeletal osteotomy and a soft tissue suspension does not work against each other. In other words, the swelling from the cheekbone reduction does not stretch out the facelift result. This would have been my concern and it is good to read that this does not appear to occur.

There was no doubt that the facelift would provide a protective function against any cheek sagging. This is a useful combination of facial procedures to restore the youthful and proportionate facial relationships in older Asian patients. Or for any cheekbone reduction procedure done in an older patient regardless of their ethnicity.

Dr. Barry Eppley

Indianapolis, Indiana

July 23rd, 2016

Case Study – Silicone Testicular Implant Replacement

 

Background: The most common device for replacement of a lost testicle is that of a saline implant. While this is the only FDA-approved implant for this purpose, it is actually not a good concept for a prosthetic device sitting in the scrotal sac. It most certainly does not feel natural (more firm than a natural testicle) and often is undersized for some men. In addition the concept of attaching it inside the scrotum using a fixation suture is prone to causing a tethering effect. Because it is a fluid-filled device a saline implant has a lifelong risk of failure by rupture of the containment shell. This will result in the need for future replacement surgeries.

A soft but solid silicone implant is far superior as a testicle implant. Very low durometer silicone that feels extremely soft (squishy) has far better material properties to reside inside the hanging and mobile scrotum. Because it is a solid implant it can also never deflate.

Exchanging a hard saline implant with a larger silicone testicle implant requires management of the capsule. If the existing implant capsule is not released (capsulotomy) or in some areas removed (capsulectomy), the implant will remain positioned too high. While no two testicles are every at exactly the same level, significant horizontal positional asymmetries are aesthetically undesireable.

Case Study: This 35 year-old male had a history of a left testicular implant placed in his teenage years after a traumatic injury caused loss of the testicle due to torsion. The implant was replaced with a larger saline implant more recently but he was unhappy with the aesthetic result. It was positioned too high and felt tethered into this position. He presented for a silicone testicular implant replacement.

Testicular Implant Capsulotomy Dr Barry Eppley IndianapolisSilicone vs Salinje Testicular Implant Dr Barry Eppley IndianapolisUnder general anesthesia his existing high inguinal incision was reopened and the indwelling saline implant removed including the fixation sutures. A new silicone implant was chosen that was 1/3 bigger. With the implant removed the scrotal sac was inverted through the incision and the implant capsule released and partially removed. This allowed the pocket to be developed to the bottom of the scrotum. The new silicone implant was then inserted. The incision was closed in layers with no fixation suture used to the implant..

Remove and Replace Testicular Implant result Dr Barry Eppley IndianapolisTesticular Implant Replacement Surgery result Dr Barry Eppley IndianapolisSilicone is a superior testicular implant material because it is softer, comes in larger sizes and will never need to be replaced due to device failure. When replacing an unsatisfactory hard saline testicular implant, almost always a larger size is needed.

Highlights:

1) Saline testicle implants can feel too firm and may be of inadequate size for some men.

2) Replacing a high tethered saline testicle implant requires a scrotal sac capsulorraphy.

3) Silicone testicle implants offer a much softer feel and bigger sizes than saline implants.

Dr. Barry Eppley

Indianapolis, Indiana

July 22nd, 2016

Case Study – Extra Large Custom Pectoral Implants

 

Background: Augmentation of the male chest is most commonly and successfully done by weight control and muscle hypertrophy and exercise. A more immediate and sustained effect that does not rely on strenuous exercise is that of pectoral implants. Such male chest augmentation devices have been around for decades and have a long track history of successful clinical outcomes. Unlike the female equivalent of breast implants, however, pectoral implants are solid devices that will never need to be replaced because of device failure. (rupture)

The styles of pectoral implants are basically either oblong or more rectangular in shape. Most men prefer the rectangular shape as it more effectively increases the fullness in the upper portion of the pectoralis muscle close to the clavicle. The rectangular shaped implant can be used either in a vertical or horizontal orientation. Its maximal volume is just under 300cc.

While these standard pectoral implants can be adequate for many cases, some men prefer a more profound chest augmentation. Or some men are simply bigger in size and weight and the standard sizes are inadequate for their aesthetic desires. In these cases custom pectoral implants have a definitive role.

Tiller Pec L XXL r3Case Study: This middle-aged male wanted a significant chest muscle enhancement. Given his large body frame (over 6’ 4” tall) and weight, all standard sized pectoral implants would have made very little change compared to his goals.  A pair of extra large custom pectoral implants were designed and made to exceed the dimensions of standard sized implants used by a considerable margin.. These custom implants were different in all dimension especially in thickness (5cm) and in total volume. (900cc)

Extra Large Custom Pectoral Imlpants intraop positioning Dr Barry Eppley IndianapolisUnder general anesthesia a 7 cm axillary incision was made in the anterior axillary skin crease. Dissection was carried under the outer border of the pectoralis muscle and a submuscular pocket created. Care was taken to not violate the attachments of the lateral border of the muscle. The extra large implants were inserted and positioned. A three layer closure was done over the exposed upper outer edge of the implants.

Extra Large Custom Pectoral Implant immediate intraop result below view Dr Barry Eppley IndianapolisExtra Large Custom Pectoral Implants intraop result right side view Dr Barry Eppley IndianapolisThe change in chest size was significant and symmetric. Interestingly the implants on the inside did not create an effect as large as one would anticipate when looking at them laying on the chest.

Extra large custom pectoral implants can be made and used when a significant chest size change is desired. It can be impressive that such a large implant can be inserted through a small axillary approach into the submuscular pocket.

Highlights:

1) Pectoral implants are the immediate, surgical and permanent method for chest muscle enhancement.

2) Standard implants are satisfactory for the vast majority of men seeking chest muscle enhancement.

3) Custom pectoral implants can be made in extra large sizes to address patient requests for extreme amounts of chest muscle augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

July 20th, 2016

Case Study – Custom Bicep Implants

 

bicep muscleBackground: The bicep muscle is the most recognized muscle of the entire arm as evidenced by someone flexing their arm to show its presence. It is a two-headed muscle that runs between the shoulder and the elbow. It has two distinct heads, known as the short and long heads, which emanate from the scapula of the shoulder. The two heads come together into a single muscle mass by the mid-portion of the upper arm. From there the muscle extends across the elbow and attaches to the radius of the forearm.

Augmentation of the bicep muscle can be done by fat injections or an implant. While both treatment methods can be effective, a biceps implant offers a reliable and permanent muscular enhancement method. These implants can inserted either under the muscle (intramuscular) or on top of it just under the fascia. Because of potential injury to the musculocutaneous motor nerve, it is preferable to opt for the subfascial placement on top of the muscle. This also creates the most visible muscle enhancement effect.

Bicep Implants Dr Barry Eppley IndianapolisThere are no formal silicone bicep implants per se. Most commonly used are either silicone calf implants or contoured carving blocks. (Implantech) Their long cylindrical shapes matches the longitudinal shape of the arm muscle. Such performed implants can achieve a 2 cm increase in muscle profile. For larger bicep implants, a custom design process must be used.

CCB3 Custom 18x 8 x 4 3D-R02-1Case Study: This middle-aged male wanted a significant biceps muscle enhancement. Given his large body frame (over 6’ 4” tall) and weight, all standard sized bicep implants were inadequate to make surgery worthwhile… or least not enough to meet the patient’s aesthetic goals. A pair of custom bicep implants were designed and made to exceed the dimensions of standard sized implants used for the biceps. These custom implants were different largely in thickness and width, the length stays the same as other implants.

Bicep Muscle Shortening Dr Barry Eppley IndianapolisWhen doing the preoperative markings for a bicep implants or in the design of custom bicep implants, it is important to appreciate how the muscle belly shortens as the arm flexes. The maximum implant length should not exceed the proximal-distal length of the muscle when in flexion. (hand bend back to the shoulder)

Bicep Implant placement technique Dr Barry Eppley IndianapolisUnder general anesthesia a 4 cm axillary incision was made in the anterior axillary skin crease. Deeper dissection led to the biceps fascia which was opened and a subfascial pocket developed. The custom bicep implants were inserted and positioned directly on top of the muscle. The fascia was closed over them as well as multiple layers beneath the skin.

Bicep Implant immediate result Dr Barry Eppley IndianapolisRight Biceps Implant result intraop Dr Barry Eppley IndianapolisThe change in arm size was immediately apparent as would be expected. Due to the soft durometer of the implants they felt fairly similar to muscle.

Custom bicep implants can be used when a bigger size is needed than what standard implants provide. In men with larger body frames a higher profile (projection) and width may be needed to create an adequate muscle enhancement effect.

Highlights:

1) Biceps implants are placed on top of the existing muscle for an enhanced upper arm profile.

2) Placed through an axillary incision, the implant is placed under the overlying fascia of the biceps muscle.

3) Custom bicep implants are bigger than standard sized implants but are placed the same way.

Dr. Barry Eppley

Indianapolis, Indiana

July 19th, 2016

The Deep Pyriform Space Implant

 

The nasolabial fold is a well known facial area that deepens with age. This has resulted in it being a common target for a variety of treatments that include injectable synthetic fillers and fat as well as the placement of subcutaneous implants. Regardless of the treatment they all are directed towards pushing out the linear skin indentation at the subcutaneous level.

pyriform aperture deep pyriform spaceIn recent anatomic studies the deep medial cheek fat compartment has a space deep to it known as Ristow’s Space. This has been described as a triangular paranasal area sitting right over the pyriform aperture. As a result of fat atrophy as well as bony resorption that occur with aging around it, Ristow’s space increases. Voluminization of this deep space has been proposed to be a new target in the treatment of the prominent nasolabial fold. The exact anatomic boundaries of this space, however, have never been precisely studied or defined.

In the July 2016 issue of Plastic and Reconstructive Surgery an article appeared entitled ‘Deep Pyriform Space: Anatomical Clarifications and Clinical Implications’. In this anatomic study the average dimensions of the deep pyriform space was essentially 1cm x 1 cm. The space has an inverted triangular shape that is bordered inferomedially by the depressor septi nasi muscle, the soft tissue attachments of the bony pyriform aperture and the retro-orbicularis fat. The premaxillary space and the levator labii superioris muscle sit above it. The angular artery lies superficial and lateral to the deep pyriform space.

The authors describe an injection technique to access this space for voluminization using blunt cannulas. With the cannula at the bone level the deep pyriform space is entered. They recommend very cohesive fillers like Radiesse or fat, presumably due to their better soft tissue push at this deep level, than hyaluronic-based fillers.

deep pyriform space implant dr barry eppley indianapolisThe deep pyriform aperture space is a midface cavity that is intimate to the pyriform aperture. It is accentuated by resorption of the face of the maxillary bone with aging. Pushing out on this space adds support to overlying cheek fat and lip elevators. Given the location of his space, it would intuitively seem like augmentation of the bone with an appropriately designed implant would provide a better long-term solution than any injectable filler.

Dr. Barry Eppley

Indianapolis, Indiana

July 18th, 2016

Case Study – Forehead Bony Reduction with Hairline Advancement

 

Background: The shape of the forehead is largely controlled by the development of the frontal bone of the skull. Frontal bossing is the term given to describe a prominent bulging forehead. This is usually most manifest in the upper forehead which can project outward beyond the wide profile of the brow bones in some cases. There are a variety of medical conditions that can cause frontal bossing from congenital skull deformities to hormonal abnormalites. (e.g., acromegaly)

But for many patients this is an aesthetic deformity that has no specific cause other than this is just how the forehead developed. The prominent upper forehead usually appears as a bulge across the upper forehead. It is obvious because it has a size bigger than the patient’s brow bones and also causes a high or long forehead in some patients. A large surface area forehead causes a facial imbalance and disrupts the aesthetic thirds of facial proportions.

Frontal bossing can be reduced to improve facial aesthetics. How much the prominent frontal bone can be reduced depends on the thickness of the bone. Burring reduction is the surgical technique, not formal bone removal (frontal craniotomy) and split bone reduction as would be done in more severe craniofacial deformities.

Case Study: This 23 year-old female had a prominent upper forehead that was aesthetically bothersome to her. She wore her hair short so the entire shape of the forehead was clearly evident.

Forehead Bony Reduction with Hairline Advancement intraop result left oblique view Dr Barry Eppley IndianapolisUnder general anesthesia a pretrichial hairline incision was used to access the forehead. Burring reduction of 5 to 6mms was done throughout the forehead bulge down to a bleeding diploic space. The frontal hairline was then advanced 1 cm from upper temporal to upper temporal areas. The combination of some reduction of the frontal bossing and skin shortening of the forehead created a more balanced looking forehead region.

Total Forehead Reduction result side view Dr Barry Eppley IndianapolisThere are limits as to how much frontal bossing can be burred down. It may be able to be burred down completely or only partially. The hairline advancement provides an adjunctive improvement as it alone creates the appearance of a smaller forehead.

Highlights:

1) Frontal bossing is an aesthetic forehead deformity that is associated with an enlarged upper forehead and a high hairline.

2) The amount of reduction possible for frontal bossing depends on the thickness of the frontal bone.

3) A pretrichial approach to forehead bony reduction allows for frontal hairline advancement as well.

Dr. Barry Eppley

Indianapolis, Indiana

July 17th, 2016

Case Study – Custom Jaw Angle Implant after BSSRO Surgery

 

Background: The most common method of corrective lower jaw surgery is the sagittal split ramus osteotomy. (BSSRO) While initially described over half a century ago, it remains the cornerstone of lower jaw repositioning surgery. It is an incredibly clever oseotomy design that I still consider a marvel of craniofacial bone surgery and remains technically challenging to perform even after having one the operation for decades.

sagittal split manidbular osteotomyLongitudinally or sagittally splitting the mandibular ramus into proximal and distal segments allows the toothbearing portion (distal segment) to be moved independently of the proximal (jaw joint containing) segment. Once the teeth are set into the desired bite, the overlapping proximal and distal segments are put back together allowing for maximal bone contact to expedite bony healing.

But the proximal mandibular segment, which provides the shape to the jaw angle, is largely stripped of its soft tissue attachments in the execution of a BSSRO. This partially devascularizing effect can cause the shape of the bone to undergo some postoperative remodeling. This can cause the shape of the jaw angle to change. While it doesn’t always occur it is probably an under reported aesthetic bony change.

Case Study: This 35 year-old female had a prior history of a mandibular osteotomy to correct a malocclusion accompanied by a sliding genioplasty. While this gave her a good bite it left her with facial asymmetry which was most pronounced at the jaw angle areas. She did have treatment with liposuction and fat grafting into the right jaw angle but this did not improve her facial asymmetry adequately.

Custom Jaw Angle Implant for Asymmetry Dr Barry Eppley IndianapolisIt was decided to perform bilateral jaw angle surgery with liposuction to the right jaw angle (to remove the injected fate) and augment the left jaw angle with a custom jaw angle implant. A 3D CT scan was used to both evaluate and design the left jaw angle implant.

Jaw Asymmetry Surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia the right jaw angle soft tissues underwent small cannula liposuction from an incision behind the earlobe. The custom jaw angle implant was placed in the left side through an intraoral incision and secured with a single 1.5mm microscrew. The combination of the right jaw angle liposuction and the left jaw angle implant improved her facial symmetry.

Deformations of the jaw angles can occur from the BSSRO procedure. The bone may heal perfectly but there can still be a change in the shape of the jaw angle due to bony resorption. Restoration or enhancement of jaw angle shape can be done with an implant. Whether the jaw angle implant would need to be custom or not depends on the degree of  bony jaw angle deformity.

Highlights:

1) Jaw angle deformation and asymmetry is not rare after sagittal split mandibular osteotomies.

2) Asymmetry of the jaw angles is best assessed by a 3D CT scan to develop an accurate appreciation of their bony differences.

3) A custom jaw angle implant is the best method to correct bony angle asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

July 17th, 2016

Case Study – Limited Incision Forehead Augmentation

 

Background: Forehead augmentation in men is often done to correct a pseudobrow protrusion deformity. This is where the position of the brows is actually normal but the superior position of the forehead is deficient. This makes the brow bones comparatively look too strong. This diagnosis can be confirmed by doing computer imaging where the forehead is either brought forward or the brow bones brought back.

In these cases of pseudobrow bone prominence, augmentation of the forehead above is the corrective aesthetic procedure. There are multiple materials to use for forehead augmentation from bone cements to custom implants. In isolated more central forehead augmentation procedures the use of bone cements is the most economical approach.

The issue with frontal cranioplasties with bone cements is that wide open access is usually needed to place them. This is particularly true with the hydroxyapatite bone cements which are like thick putty when mixed and do not have good material flow. A near or complete coronal scalp incision is needed to ensure even application and good feathering at the edges. PMMA bone cement, however, has different material flow properties that permit smaller incisional application.

Case Study: This 25 year-old male was bothered by his prominent brow bones. Through computer imaging it was shown that his forehead above the brow bones was recessed. Augmentation of his forehead above the brow bones was determined to create the best aesthetic result.

Limited Frontal Cranioplasty incision and closure Dr Barry Eppley IndianapolisUnder general anesthesia an 11 cm long irregular scalp incision  was made 3 cms behind the frontal hairline. Subperiosteal dissection was made down to the brow bones and out past the anterior temporal lines. Using PMMA bone cement mixed with antibiotic powder a putty was created. The putty was inserted into the pocket and then shaped through external molding with particular attention paid to creating smooth edge transitions across the brow and temporal lines. Any excess was pushed towards the incision where it was removed before the material completely set. A hand piece and burr was then used to make sure all visible edges were feathered.

Forehead Augmentation with PMMA intraop result Dr Barry Eppley IndianapolisA frontal cranioplasty using PMMA bone cement can be done through a more limited scalp incision. The material flows well and can be shaped externally as it sets. It takes good experience working with the material to be able to get a good shape of it in a partially blinded fashion. Meticulous attention was be paid to edging and the detection and elimination of any irregularities. If any exist they will eventually be seen moths laters when the forehead tissues have fully contracted.

Highlights:

1) Forehead augmentation in men can be done to include the brow bones or done in isolation for the forehead region above it.

2) Using bone cement for forehead augmentation typically requires a long scalp (coronal) incision.

3) Using PMMA bone cement a limited scalp incision can be used for forehead augmentation…if one has a lot of experience using this type of bone cement.

Dr. Barry Eppley

Indianapolis, Indiana

July 15th, 2016

Suture Closure in Open Rhinoplasty

 

An open technique for rhinoplasty is the most common approach used today by most plastic surgeons. While this does create a mid-columellar scar, it usually heals in almost to completely undetectable skin scar when careful attention is paid to its closure. Many surgeons uses skin sutures in this area that require secondary removal. While this may only be four or five sutures, this nasal area is very tender at this early point after surgery and neither the patient or surgeon look forward to their extraction.

In the August 2016 issue of the Aesthetic Plastic Surgery journal, an article appeared entitled ‘Rapid Resorbable Sutures Are a Favourable Alternative to Non-resorbable Sutures in Closing Transcolumellar Incision in Rhinoplasty’. The purpose of this reported study was to determine if rapid resorbable sutures could replace non-resorbable sutures in nasal transcolumellar incisions. This was assessed by looking at 41 rhinoplasty patients using columellar inverted-V incisions comparing patient discomfort, scarring and the risk for postoperative infection. Interestingly many of the patients were of Middle Eastern descent. (65%)The first 21 patients were sutured with non-resorbable 5-0 Prolene and the subsequent 20 patients with a rapidly resorbable suture material, the 5-0 Vicryl Rapide.

The results of the study showed that trimming the knots of the Vicryl sutures was significantly less uncomfortable than the removal of the Prolene sutures. Almost 1/3 of the suture extraction patients found it to be very painful. Almost all patients (98 %) found their columellar scars as aesthetically acceptable. In addition, most of the patients considered their scars to be invisible. No postoperative infection occurred in any of the study patients. In conclusion, closing the columellar incision in rhinoplasty withs rapid resorbable sutures caused significantly less discomfort but a similar superb scar appearance to non-resorbable sutures.

This study confirms what I have practiced for more than a decade in open rhinoplasty surgery. I converted to 6-0 plain (an even faster resorbing suture that does not even require trimming of the knot) to close the transcolumellar incision long ago and have seen the same similar scar results. The only time I use removeable sutures now is when there is some tension of the columellar closure usually due to significant tip projection increase.

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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