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.

February 25th, 2018

Case Study – Ear Reconstruction with Skin Flap and Rolled ePTFE

 

Background: As a projecting structure from the side of the head with a funnel-like and flexible attachment, the ear can withstand a wide variety of deforming forces. Its very flexibility protects it from injury when exposed to shearing forces. Like a palm tree in high winds its ability to bend is a protective mechanism.

But when the ear is grabbed by a sharp or compressive force, it is going to tear and suffer a partial loss…or even a total detachment from its base. This occurs in the ear from bite injuries, whether it be from an animal or a human. Loss of portions of the ear from such injuries are well chronicled.

Reconstruction of missing portions of the ear almost always requires a composite technique as both skin and cartilage are needed. The skin is needed to provide an epithelized cover and cartilage is needed to restore framework support for any of its convex or tiered levels. Such methods of ear reconstruction have a long history and date back well into the history of plastic surgery.

Case Study: This young man sustained a human bite injury to his upper ear with loss of a segment of the helical rim. It was well healed and had a combined skin and cartilage defect. The amount of loss could be seen when compared to his opposite normal ear.

A first stage procedures was performed to create more skin for coverage of the helical rim using a postauricular flap technique. This is done by attaching the anterior edge of the ear defect to the postauricular skin.

At three weeks after the postauricular skin flat attachment, it was separated from its base to create a roll of helical rim skin. The helical rim cartilage was reconstructed using a piece of rolled ePTFE material which was sutured to the cartilage. The roll of ‘new’ skin was then used to cover the implant and sutured over it on the back side of the ear.

This two-stage well known ear reconstruction method is a very effective technique. While  the skin roll alone is often used to make the helical rim, I prefer to provide support to the skin roll so it does not contract and become distorted. While a thin rib cartilage graft could be used for this purpose, a thin roll of ePTFE material saves a donor site and provides good support without any risk of warping like a rib cartilage graft might.

Highlights:

1) Loss of ear segments usually requires both cartilage and skin replacements.

2) The skin for helical rim reconstruction can be created from a two-stage postauricular skin flap.

3) Helical rim framework reconstruction can be done with a rolled alloplastic material like ePTFE.

Dr. Barry Eppley

Indianapolis, Indiana

February 25th, 2018

The Medial Epicanthoplasty in Asian Eyelid Surgery

 

The lack of a well defined upper eyelid crease in combination with an epicanthal fold is the most common aesthetic Asian eyelid ‘deformity’. I put the word deformity in parentheses because it is very common to have a monolid in Asians and it is not really a true deformity in the biologic sense. But it is most certainly the single one feature that is most commonly treated by aesthetic surgery in the Asian face.

A wide variety of double eyelid procedures have been described from non-excisional suture methods to open excisional suture techniques. There is no one uniformly accepted method. The same may be said for the accompanying epicanthal fold. Despite its small size, an equally diverse number of tissue rearrangement techniques have been described for it.

What is unique about the epicanthal fold compared to the eyelid crease is that the concern about scarring is more significant. The scar in double eyelid surgery is the actual skin crease whose presence is usually seen as a good thing as long as it is not excessive or hypertrophic. A prominent line or scar at the inner eye from a medial epicanthoplasty, however, is not so favorably seen. This is why tissue arrangement patterns have been devised for it in an effort to minimize scarring in an area where the margin between a good looking scar and that of an undesirable one can be very narrow.

Careful analysis of medial epicanthoplasty options show that many of the most commonly used techniques have more rather than less in common. Almost all involve some excision of the medial epicanthal skin fold and a tissue rearrangement technique that exposes more of the lacrimal lake and opens up the eye in the horizontal dimension. The modified z-epicanthoplasty is the most widely used technique due to its versatility, ability to avoid too much tension on the suture line and generally offers minimal scarring.

Dr. Barry Eppley

Indianapolis, Indiana

February 24th, 2018

Case Study – Reconstruction of the Burned Ear

 

Background: As a projecting facial structure the ear is exposed to a variety of traumatic insults. One such type of traumatic ear injury is that of burns. Most commonly occurring in house and other entrapped fire situations, the sustained exposure  to high heat often causes a melted ear appearance. The anterior exposed ear surface often sustains severe and full-thickness burns of the skin and underling cartilage surfaces. The back of the ear is the more protected surface and the postauricular skin and sulcus is often fully preserved or has sustained far less burn injury

While the vast majority of thermal injuries to the ear are due to flames and high heat, another type of burn injury is that caused by chemicals. Chemical burn injuries to the ear are very different from those of high heat. Creating a splash type of contact the burn pattern may not always be on the front of the ear. While the front of the ear is still its most exposed surface, it is possible that the back of the ear can be injured more than the front of the ear. Liquid burn injuries are also somewhat more limited to the contact area without the typical progression of the tissue death associated with high heat damage.

Reconstruction of the burned ear can be challenging because of the loss of normal pliable skin on and around the ear. Often the cartilage structure may be partially or completely useable but scarred and inflexible skin prevents the ear from being separated from the side of the head.

Case Study: This unfortunate female sustained severe scalp and facial burns due to having acid thrown on her. She had undergone numerous skin grafting procedures and her final area to be reconstructed was the of her left ear. The ear was fused to the side of the ear with an indistinct demarcation from the lobule all the way around the superior helical root. There was complete effacement of the postauricular sulcus.

Due to the tightness of the burned skin, a small tissue expander was placed in the non-hair bearing skin area above the ear. While some small amount of skin expansion was possible the tissues became too tight and the expansion concept was abandoned.

It was then elected to do a wide release around the perceived helical rim margin of the ear. This allowed a skin flap to be made based on the skin circulation through the largely uninjured anterior ear surface. This skin flap was used to fold under the released cartilage framework. The large skin defect site created behind the ear was then skin grafted. The resultant ear reconstruction produced a more normal ear appearance.

The success of this particular ear reconstruction was largely due to having a preserved cartilage framework. It was the loss of skin surface coverage and the postauricular sulcus that constituted its deformity.

Highlights:

1) Traumatic loss of skin behind the ear causes a fusion of the helical rim to the mastoid skin behind the ear.

2) Tissue expansion and skin grafts can be used to release and reconstruct the postauricular sulcus and nastoid skin surface of the burned ear deformity.

3) The successful reconstruction of a burned ear’s appearance is often based on how well the anterior cartilage structures are preserved.

Dr. Barry Eppley

Indianapolis, Indiana

February 24th, 2018

Plastic Surgery Case Study – Combining A Custom Jawline Implant with a Sliding Genioplasty

 

Background: Custom jawline implants are usually the best surgical method for changing the 3D shape of the lower face. Through a computer-designing process an implant can be designed to cover jaw angle to jaw angle crossing the chin in the middle. Covering such a large bony surface area, even when the dimensions of the implant seem fairly small, can have a more powerful effect on jaw augmentation than the numbers alone would lead one to think.

A custom jawline implant works, like all implants anywhere on the body, by pushing out the overlying soft tissue to create its aesthetic effects. But the ability of the soft tissues to expand is not the same across the jawline. The jaw angle tissues are softer and more expandable than that of the chin. As the chin is a projecting bony structure the soft tissues over it are tighter and more attached than any other tissues along the jawline.

The tightness of the soft tissues over the bony chin pose some considerations when larger chin augmentations are desired, particularly when an implant is being used to do it.  How well will the soft tissues be pushed out, what happens to the depth of the labiomental fold and what are the long-term implieations of having a large implant load in the chin? For these reasons some patients may feel more comfortable with bony sliding genioplasty for their chin augmentation rather than using an implants. But can a sliding geniplasty be combined with an implant to augment the jawline behind it?

Case Study: This young male wanted to augment his entire jawline. By computer imaging it was determined that the chin part of the augmentation needed to come forward around 12mms and he was more comfortable with moving the chin bone rather than doing it with an implant.

Using a 3D CT scan the sliding genioplasty was simulated with a 10mm horizontal movement with a 3mm vertical opening. A custom jawline implant was then designed to augment the jaw angles and come forward to cross the chin with a 2mm overlay on top of the sliding genioplasty

Under general anesthesia and through three intraoral incisions, the sliding genioplasty was first performed, moving the chin 10mms forward and down 3mms as preoperatively designed. The custom jawline implant was then split in the middle and then threaded into place in a back to front techique. The implant was reunited in the middle and secured to the sliding geniplasty chin segment with microscrews.

A custom jawline implant can be combined with a sliding genioplasty in a synergistic manner to create a total jawline augmentation effect. This auto-alloplastic approach to jawline augmentation can only be effectively done with a 3D computer designing process.

Highlights:

1) Large amounts of chin augmentation with an implant may exceed the tolerance of the soft tissue chin pad.

2) A sliding genioplasty is often better long-term for the soft tissue chin pad in larger advancements but it does cause side or lateral wing aesthetic deformities and will make the chin appear less wide.

3) Custom jawline implants can be combined with a sliding genioplasty to create a wider chin and a smoother jawline back to augmented jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

February 24th, 2018

Facial Fat Grafting and Platelet-Rich Plasma (PRP)

 

Fat grafting is the primary surgical technique to soft tissue augmentation of the face. The addition of fat cells has the potential to add retained volume while the presence of adipose-derived stem cells offers the opportunity for tissue regeneration. Such tissue regenerative effects may be able to be seen in the overlying skin with an improved appearance and elasticity.

Efforts to improve the potential benefits of the adipose-derived stem cells in the fat graft have been based on graft concentration techniques. Another potential method has been the addition of agents to the graft concentrate that can cause cell stimulation. While no one single agent has yet been identified that can do so, the most theoretically promising is that of platelet-rich plasma.(PRP) As an autologous concentrate from a blood draw, it offers a rich source of growth factors that can be mixed with the fat concentrate and may aid the regenerative effects of the adipose-derived stem cells. While the addition of PRP to a fat graft intuitively seems to be beneficial, there are few clinical studies that have studied such a facial lipofilling combination.

In the February 2018 issue of the journal Plastic and Reconstructive Surgery an article was published on this topic entitled ‘The Addition of Platelet-Rich Plasma to Facial Lipofilling: A Double-Blind, Placebo-Controlled, Randomized Trial’. In this paper the authors conducted a clinical study over three years in thirty-one (31) females who had facial fat micrografting done with both superficial and deep lipofilling on both sides of the face. The fat injected areas were then treated by secondary injection of either the saline (control) or PRP. Postoperative assessment was based volume retention at the nasolabial folds, skin elasticity, recovery time and patient satisfaction one year later.

Their results showed that the addition of PRP did not improve fat graft maintenance or skin elasticity improvement. PRP did, however, significantly reduce postoperative recovery time. This was judged by a quicker return to work and decreased time needed for the use of camouflaging agents for the post-injection bruising.

This clinical study of the potential value of PRP is hampered by the unknown question of how much concentration of it is needed. Since it is not a drug, no studies have ever been done to evaluate dosing. This is not to mention the various method/kits used to prepare it. Also should the PRP be mixed in with the fat graft or injected after the fat graft has been placed as the authors have done in this study.

How does platelet-rich plasma improve recovery after facial fat grafting? The hypothesis is it induces increased fibroblastic activity, increased collagen production and a stimulation of an enhanced inflammatory response.

Dr. Barry Eppley

Indianapolis, Indiana

February 21st, 2018

Management Strategies for the Thickness-Skinned Nose in Rhinoplasty

 

The thickness of the nasal skin has a well known important influence on the outcome of rhinoplasty. Such skin thickness can have either be a favorable or an unfavorable effect on the eventual shape of the nose. By far surgeons would much rather have thinner skin but there is no avoiding the thick-skinned rhinoplasty patient who usually has the aesthetic objectives of what can only be accomplished in a thinner-skinned nose.

The needed soft tissue contraction and shrink wrap effect that is necessary to reveal the osteocartilaginous changes in the nasal framework does not usually occur in the thick-skinned nose. Besides the thick dermis in these patients the underlying SMAS layer is also hypertrophic. This ultra thick skin coverage is often combined with weak underlying carriages to create a wide and amorphous looking tip. After surgery the lack of good contractile properties of the skin with its propensity for prolonged swelling make for a tenous and difficult postoperative course. When substantial augmentation of the nose is needed, thick skin is less problematic. But when combined with the need for structural support reduction, the worst case scenario for a satisfactory aesthetic result is created.

In the February 2018 issue of the journal Facial Plastic Surgery an article was published entitled ‘Surgical Management of the Thick-Skinned Nose’. In this paper the authors provided a comprehensive overview of all known and accepted methods for improving the outcomes of rhinoplasty surgery in the thick-skinned nose patient. The one and most well known intraoperative technique is that of SMAS debulking which can be safely performed in an open rhinoplasty with attention paid to preservation of the lateral nasal arteries near the supra-alar crease. Such SMAS excision should be limited to thick noses that are 5mms or greater in thickness. It can be safely used in both primary and revision rhinoplasty.

One other intraoperative technique I like is the use of a thin layer of gelfoam soaked in triamcinolone (Kenalog) which is applied in the supra tip area.

Immediate postoperative management includes a variety of frequently used techniques including head elevation, periorbital-nasal application of ice and intranasal steroid sprays. (fluticasone)

Beginning weeks to months after surgery, low-dose steroid injections often combined with 5-FU remains the mainstay of postoperative management of the thick nose.

In thick-skinned noses that are acne prone, presurgical control of the acne is important. But when such noses have developed postoperative flares the use of low dose Accutane  for four to six months after surgery can be useful.

While there is no magical solution to ensure that the thick-skinned nose patient will have a complaint soft tissue cover, application of many of the methods described in this paper will be of benefit.

Dr. Barry Eppley

Indianapolis, Indiana

February 18th, 2018

5-FU Injections in Rhinoplasty

 

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

February 18th, 2018

Technical Strategies – Intraoperative Positioning Guides for Custom Jawline Implants

 

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

February 17th, 2018

Case Study – Female Custom Chin Implant

 

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

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

February 17th, 2018

Case Study – Arm Lifts after Weight Loss

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

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana


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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