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.

August 20th, 2017

Case Study – Cranial Bone Graft Rhinoplasty with Medial Canthoplasties

 

Background: Fractures to the nose most commonly result in nasal deviations as the direction of the force usually comes from the side. (e.g.,fists) But direct trauma to the nose results in impaction injuries which push the nose inward resulting in loss of bridge height and a collapsed nasal appearance.

The most severe type of nasal impaction injury comes from high velocity forces such as motor vehicle accidents. This not only pushes the nose in but the extension of the fracture lines and bony displacement extends to the medial orbits as well. This results in not only the nose being pushed inward but the attachments of the eyelids (medial canthi) end up being  displaced laterally. These traumatic nose and eye changes create what is known as a traumatic hypertelorism effect. (technically pseudohypertelorism) This can be very hard to correct during the initial fracture repair and often requires secondary surgery for a more complete correction.

Case Study: This teenage female was involved in an ATV accident where she sustained blunt trauma to her face at the frontonasal area by striking a tree. She sustained a severe naso-ethmoid fracture pattern as well as other facial bone fractures. She underwent primary facial fractures repair any another facility, part of which was done through a coronal scalp incision. When seen six months after her initial injury and repair, she had a telecanthic appearance with indentation of her nasal bridge.

Under general anesthesia, her original coronal scalp incision was opened and  the scalp reflected down to the nasofrontal junction. A split-thickness outer table cranial bone graft was harvested from the left posterior forehead region which had a minimal curvature to it. The graft was shaped to fit the length of the nose and inserted into a nasal pocket and secured at its superior end with a 2.0 molar screw. The graft donor site was reconstructed to contour with hydroxyapatite cement. Medial canthoplasties using 3o0 gauge wires was also done, passing it under the cranial bone graft.

At five years after her secondary nasal reconstruction, her dorsal nasal height remained stable and straight. The bone graft showed no signs of resorption.

Her eyes appears closer together which was probably as much the result of a heightened nasal bridge as the medial canthoplasties.

Highlights:

  1. One graft option in nasal reconstruction is cranial bone due to its anatomic proximity.
  2. Cranial bone grafts to the nose usually undergo minimal long-term resorption
  3. Through a coronal scalp incision, a cranial bone graft to the nose can be done with medial canthoplasties in the treatment of traumatic hypertelorism.

Dr. Barry Eppley

Indianapolis, Indiana

August 20th, 2017

Case Study – Hydroxyapatite Granule Skull Reconstruction

 

Background: The skull, while often perceived as a solid piece of bone, is not. It is actually composed of three layers, very much like an Oreo cookie. There are the outer and inner solid cortical layers (the cookie) and then there is a thinner inner layer which is softer known as the diploid or marrow space. (the filling)

Many skull defects occur as a result of injuries caused by fractures of varying degrees of the bone’s thickness. When the skull fracture does not significantly displace the inner cortical table and does not disrupt the dura, there is no need for surgical reduction. But such fractures often do displace the outer cortical table resulting in contour defects. The soft tissue will eventually follow the depressed bone inward as scar contracture and healing ensure.

Case Study: This 24 year-old male was involved in a car accident in which he sustained blunt trauma to his right upper forehead. He sustained a full thickness skull fracture with a small underlying epidural bleed. He was not treated surgically and he went on to a full recovery. As he healed he developed a circular indentation over the fracture site. A 3D CT scan showed that it was due to a bone indentation caused by his previous skull fracture.

Under general anesthesia, a semicircular hairline incision was made for access and the defect exposed. The fractured bone was stable and no effort was made to elevate the fracture segments. The defect was filled with hydroxyapatite granules and covered with a 1m thick resorbable plate with screws for containment.

His after surgery result showed the restoration of a smooth external forehead/skull contour.

The use of hydroxyapatite bone substitute today in skull reconstruction, and for almost the past twenty years now, has been with using it in a bone cement form. This provides the best method of application as it is contoured into the defect site and then sets before wound closure. But hydroxyapatite can be still used in granular form which allows for true fibrovascular ingrowth and even some bone ingrowth as well. Its use is restricted to a completely contained skull defect with an underlying floor and walls.

Highlights:

  1. Small skull defects can be treated by a wide variety of cranioplasty materials.
  2. In a small partial-thickness skull defect, hydroxyapatite granules can be used to fill the defect and create a smooth cranial contour.
  3. A resorbable cover can be used as a roof for a hydroxyapatite granule skull reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

August 19th, 2017

Case Study – Multiple Lipoma Excisions in Familial Lipomatosis

 

Background: Familial multiple lipomatosis (FLM) is a well known condition that is associated with the lifelong development of lipomatous tumors. These lipomas occur almost exclusively on the trunk and extremities with the head, neck and shoulders usually being spared. It has been identified as an autosomal dominant condition that has been associated with chromosome 12q15.

The typical lipoma has a surrounding capsule and appears as a solitary lesion of various sizes. But the lipomas that occur in FLM are multiple, are often in clusters or a chain and have been described as more rubbery in feel. While most are asymptomatic, their location and size often make them painful.

The surgical treatment of the lipomas in FLM is excision. These excisions are usually done periodically throughout the patient’s life based on those that are associated with pain or significant cosmetic deformity. While the excisions may cure those that are removed, new lipomas will likely develop in contiguous locations in the future.

Case Study: This 60 year-old male with known FLM presented for a more comprehensive approach to his lipoma excisions. He had been through multiple lipoma excisions up to this point in life but were always limited to a handful at a time.

Under general anesthesia, 85 lesions sites of the upper arms, stomach and thighs were treated through an ‘expressive excision’ technique. This is where the skin incision is relatively small through which blunt undermining around the lipoma(s) is done. Then manual pressure is applied to basically squeeze the lipomas out through the small incision. With this method over 235 lipomas were removed over a three hour operation.

While a comprehensive approach to multiple lipomas requires a lot of incisions and resultant scars, the expressive excision technique keeps the length of each incision relatively small with a very low risk of infection or bleeding.

Highlights:

  1. Familial lipomatosis creates the need for recurrent excisions of symptomatic lipomas throughout the patient’s life.
  2. In removing large numbers of lipomas an ‘expressive excision’ technique is the most efficient method.
  3. While excision is not a cure for FLM lipomas, single session large number removals can provide long periods of symptom relief.

Dr. Barry Eppley

Indianapolis, Indiana

August 17th, 2017

Technical Strategies – Multi-Point Temporal Artery Ligation

 

The development of visible temporal arteries in the forehead is not rare. Occurring almost exclusively in men, the frontal or anterior branch of the superficial temporal artery becomes dilated and its course up into the forehead becomes prominent. Often occurring after exercise, heat exposure or alcohol intake, the muscular walls if the artery dilate makes its course very visible. In some patients the size of the artery may decrease but in other patients it may persist for days. While this is largely as aesthetic issue, some patients complain of associated headaches and even visual blurring.

Temporal artery ligation is the surgical treatment for such aesthetic forehead vessel dilatations. It should be not confused, however, with the ligation technique done for temporal arteritis or temporal artery biopsy. While that procedure does ligate (and remove a section) of the vessel, its intent is not to stop the flow through the artery. It is to remove a section of the vessel for pathologic analysis. Any blood flow reduction is an inadvertent side effect.

But aesthetic temporal artery ligation is done with the intent of ceasing flow through the prominent section of the artery. If flood is diminished or eliminated it will no longer be visible. While it may seem like ligating the vessel before it ever enters the non-hair bearing temporal and forehead areas should work, it often by itself does not. This only treats one part of the problem, inflow or anterograde flow. It does not account for back flow or retrograde flow which comes from the cross-connections across the scalp.

The real key to the procedure is to carefully trace the pattern of the vessel forward and look for branching points. At these identified branching points ligations must be done to cut off back flow once forward flow is eliminated. This can be difficult to always completely identify as the artery has a very tortuous pattern in the forehead. Sometimes they are visible but many times it requires careful palpation to find them.

The number of temporal artery ligations points will vary for each patient but can range from two to seven. The average number is three per side. Men who shave the head or have closely cropped hair often undergo more ligation points due to greater vessel exposure along its length. In the forehead area it is also important to place the small incisions in natural skin wrinkle lines which can be found by having the patient raise their eyebrows.

Dr. Barry Eppley

Indianapolis, Indiana

August 17th, 2017

Temporal Anatomy – Implications for Injection and Temporal Implant Augmentation Methods

 

Temporal hollowing has become a target for aesthetic treatments with the expansion of injection therapies. Injectable fillers and fat injections are the most common temporal augmentation methods. The ease of their use as non-surgical and minimally invasive treatments makes them very appealing to patients and doctors alike. However the temporal region is one of the least satisfying facial areas for injection from an aesthetic standpoint due to unpredictable volume retentions and evenness of the result. In addition, although rare, complications such as blindness and cerebral emboli have been reported. Understanding the anatomy of the temporal would help provide safe guidelines for injectors.

In the September 2017 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Anatomical Study of Temporal Fat Compartments and its Clinical Application for Temporal Fat Grafting’. In this beautifully illustrated cadaveric study, the authors dissected both sides of the temporal regions in eight cadavers looking at its neurovascular and fat compartment anatomy. Their specific intent was to understand the anatomy for the purposes of safe injectable fat grafting. In the subcutaneous layer two fat compartments were identified as a lateral temporal cheek and lateral orbital compartments. In the deeper loose areolar tissue upper and lower temporal fat compartments were found. The anterior branch of the superficial temporal artery and the frontal branch of the facial nerve are located in the superficial temporal fascia. The nerve runs parallel with the artery. The sentinel vein has a vertical orientation and runs just behind the lateral orbital rim through the superficial and deep temporal fascia to drain into the middle temporal vein deep into the muscle.

Based on these studies, the authors conclude that all four fat compartments above the deep temporal fascia are good sites for injection augmentation, particularly fat grafting. Because of the location of the upward course of the neurovascular structures, injecting at at or behind the front edge of the temporal hairline is safe. It is most safe when done in the upper half of this temporal region. Because of the location of the sentinel vein and the frontal branch of the facial nerve, the front half of the lower temporal compartment should be approached with caution or avoided completely.

While this study was done for the purposes of augmentation done above the deep temporal fascia, it validates the safety of temporal implants…the only method of assured permanent temporal augmentation that also creates a smooth out contour. Since temporal implants are placed under the deep temporal fascia, they avoid all neurovascular structures and have no risks of many of the potential injectable temporal augmentation problems. Surgical access is done behind the front edge of the temporal hairline, a safe zone substantiated by this anatomic study. Only the anterior branch of the superficial temporal artery and the auriculotemporal nerve are in this area, both structures which are easily avoided or can be transected without any adverse sequelae.

Dr. Barry Eppley

Indianapolis, Indiana

August 16th, 2017

Cellutone – New Technology for Cellulite Reduction

 

Today’s non-surgical body contouring can be done by wide variety of devices that produce their effects through different energies. From mechanical to ultrasonic to radio frequency, externally applied energy-based treatments have proven effects on fat reduction and skin tightening. Unlike surgery, these body contouring treatments take time to work and patients will go through a series of treatments spread out over weeks to months for their full effects to be seen.

One of the newer energy-based body contouring treatments is that of Cellutone. This is a device that uses therapeutic mechanical vibrations. This oscillating massage therapy improves the circulation, enhances lymphatic drainage and remodels collagen fibers, all effects that help improve the lumps and bumps associated with cellulite and improves skin texture. It can be used in a variety of body areas including the stomach, buttocks, thighs and flanks to name the most common treatment areas that are associated with the occurrence of cellulite.

What makes Cellutone unique from other cellulite treatments is that it uses targeted mechanical vibrations which  are stronger and go deeper into the tissue. This translate into fewer treatment sessions and earlier visible results.

The application of Cellutone through a special handpiece is pain-free and has no downtime. There is no need to take off work and stop any form of physical activity after a treatment. It is applied by gentle pressure and is done in a square-shaped grid motion across the skin of the treated area. The vibrations cause no pain but mild and very temporary side effects after is common and can include redness, itching and some very minor swelling. The most common treatment plan is a series of 4 to 6 sessions over a few weeks.

Cellutone can done alone or used with other body contouring treatments for an enhanced effect of their treatments. When combined with Vanquish or Exilis better fat reduction and skin tightening can be seen. It is also a useful postoperative treatment after liposuction to improve the resolution of swelling and shaping of the skin back down after the fat reduced treatment areas.

Dr. Barry Eppley

Indianapolis, Indiana

August 16th, 2017

Technical Strategies – Gummy Smile Correction Techniques

 

The gummy smile is a well known perioral appearance that occurs when too much of the gums (gingiva) shows when smiling. The interpretation of too much gingival show will vary amongst different people and their aesthetic sense. But the general aesthetic standard is that if more than a few millimeters shows when smiling it would be considered excessive.

There are a variety of causes of a gummy smile and can include vertical maxillary excess,  hyperactive lip elevators and even a short dental crown length. This leads to a variety of treatment strategies from dental crown lengthening to a maxillary impaction surgery. Selecting the best treatment depends on classifying the degree of gum exposure. If it is just a few millimeters of excess, crown lengthening may be considered. If excessive gum shows with the mouth at rest, maxillary impaction surgery would be best.

But the majority of gummy smiles are between these two extremes and neither crown lengthening or maxillary surgery are appropriate. The most common gummy smile surgery is the shortening or reversal vestibuloplasty. This is a lip repositioning procedure that drops down the height of the depth of the vestibule. By doing the attachment of the lip on the pre maxilla got a lower position the excursion of the upper lip is less when smiling and less or no gum shows.

It is important when doing a shortening vestibuloplasty that it is not placed too low. The absolute lower limit is at the level of the mucogingival margin. Trying to suture tissue lower than this level is difficult and also risks compromising the attached gingiva. The question is really how much higher should it be if at all?

This amount is determined by first measuring how much the upper lip elevates. This vertical measurement is taken from the incisal edge of the maxillary incisors when smiling and any tooth exposure when the lip is at rest subtracted. This number is then taken and is the vertical distance the vestibule needs to be lowered. This helps make markings on the alveolar and lip mucosa for the removal of the intervening tissue and the subsequent vestibular shortening.

One additional technique that I find useful in gummy smile surgery is the use of levator quadratus superioris muscle release. (myotomy) Once the mucous is removed the muscle can be directly accessed and released. This adds to the effect of the vestibuloplasty in decreasing upper lip elevation.

Dr. Barry Eppley

Indianapolis, Indiana

August 13th, 2017

OR Snapshots – Sagittal Crest Skull Reduction

 

A bony ridge that runs down the midline of the head is known as a sagittal crest. This is a palpable raised ridge of bone that when high enough can cause a peak-shape to the head from the front view. The normal more convex shape off the head becomes more triangular shaped. This is most commonly an aesthetic concern in the male that either has very short hair or shaves their head.

Reduction of the sagittal crest skull deformity is done with a burring technique. Using a high speed handpiece and carbide burr, the bone is shaved down to a smooth contour. The bony ridge is thicker than normal skull bone so it can be safely reduced. But because this is an aesthetic deformity thoughtful consideration must be given to the incision needed to do the burring.

Working through a small scalp incision using a high speed handpiece safely requires protection of the surrounding hair and skin edges. This is best done by stapling gauze sponges along the edges of the scalp incision as well as placing a rubber guard over the length of the shaft of the burr. This prevents any risk of hair getting caught up in the rapidly rotating burr or its shaft. It is also important to only operate the handpiece when totally inside the subperiosteal tissue tunnel along the bony sagittal ridge.

Sagittal crest skull reduction can be done both effectively and safely through a fairly small scalp incision. This incision is usually placed perpendicular to the sagittal crest. In posterior sagittal crests the incision is placed on its most posterior end. But in long or more extensive sagittal crests the incision is placed at its midpoint to provide equal access to both ends of the bony deformity.

Dr. Barry Eppley

Indianapolis, Indiana

August 12th, 2017

OR Snapshots – Custom Occipital Skull Implant

 

There are over fifteen types of aesthetic skull deformities. But the most common amongst them is various forms of flattening of the back of head. Perhaps because the back of head is exposed to various pressures in utero and after birth more than any other area of the head, it is prone to deformational pressures that can cause its shape to be flatter. This flatness can affect just one (plagiocephaly), both sides (brachycephaly) or even subtotal portions of either side.

The most effective treatment for flat back of the heads, regardless of its size, is a custom occipital skull implant. Made from the patient’s 3D CT scan, the implant design can be made to cover all flat areas and match any asymmetries between the right and left sides. The flexibility of a silicone implant allows the precisely-designed implant to be inserted through the smallest possible scalp incision usually placed at the mid-portion of the occipital scalp.

In surgery the flatness of the head can be fully appreciated. With the patient asleep in the prone position, wetting of the hair allows the back of the head shape to be completely seen. Laying the custom implant on it allows one to see how much the contour can be improved. Because it is not under the scalp its size looks smaller than the bone area that it will cover and shows more projection that will be actually achieved.

Recovery from skull implant surgery is fairly quick. One can expect some swelling and bruising in the temporal areas on the sides where the implant is primarily placed. This is to be expected due to the subperiosteal dissection needed to make the implant pocket. Since the dissection is done under general anesthesia in the prone position, combined with effects of gravity, such tissue fluids work their way towards the face. The facial swelling and bruising resolves by ten days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

August 12th, 2017

Technical Strategies – Fishtail Earlobe Reshaping in Otoplasty

 

Otoplasty or ear pinning is the most common aesthetic surgery performed on the ear and its cartilages. (technically earlobe repair would be the most common aesthetic ear surgery… but it contains no cartilage)  In repositioning the shape of the protruding ear back towards the side of the head a variety of techniques are used to reshape the underlying supporting ear cartilages. Some of these are suture plications while others involve modification or removal of sections of ill-formed cartilage.

But in ear reshaping surgery consideration must be given to the only non-cartilaginous structure of the ear…the earlobe. This small area of the ear is frequently overlooked in otoplasty and can mar the aesthetic result of an otherwise pleasing reshaped ear. In many cases if the cartilage of the ear its pulled back but the earlobe remains too far forward, the ear will still standout but to a lesser degree. A protruding earlobe disturbs an otherwise smooth helical rim line from the top of the ear downward. Such otoplasty patients with earlobes that need to be simultaneously addressed can be identified beforehand.

As part of an otoplasty I frequently reposition the earlobe as well. I use excision of a segment of skin on the back side of the earlobe in a fishtail pattern. This skin section is removed with care taken to not cut through to the other side. In closing this open area on the back of the earlobe,  the outerearlobe is pulled back but avoids becoming pinched or developing a dogear skin redundancy at its bottom edge. It is the fishtail pattern that prevents the bottom of the earlobe from becoming too pinched. This is effective whether the patient has attached or detached earlobes from the side of the face.

A pleasing otoplasty result must frequently involve earlobe reshaping as well. Establishing a smooth contour from the top of the ear down to the bottom of the earlobe prevents any part of the ear from standing out..which in otoplasty surgery is the main goal. The ears needs to blend into the side of the head in a non-prominent fashion. While the ear has a complexity of hills and valleys and is artistically shaped, it still is not aesthetically pleasing to have it be more dominant than other facial features.

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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