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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.

June 23rd, 2017

Case Study – Breast Augmentation with Nipple Lift for Asymmetry Correction

 

Background: Many women that present for breast augmentation surgery do not have perfectly symmetric breasts. Women that have never had breast implant surgery rarely have symmetric breasts either. Yet, understandably, the woman who undergoes elective aesthetic breast surgery seeks the most symmetric result possible.

Of all the aesthetic breast deformities that exist, asymmetry is the most common and comes in many forms. The breast mound may be smaller on one side, there may be more sagging on one breast versus the other and/or the nipple may be lower. Since every women has some degree of asymmetry it behooves the surgeon and the patient to take careful note of it before surgery when a plan for intraoperative management can be done.

Differences in the horizontal level of the nipple is a very important asymmetry to note before surgery as breast augmentation will almost always make it worse. It is also often correctable by an adjustment done directly on the nipple. Known as a superior crescent mastopexy (SCM), ity is better referred to as a superior nipple lift. The superior half of the lower nipple can be lifted upward by about a centimeter or so through a crescent-shaped skin excision pattern.

Case Study: This 36 year-old female wanted a better breast shape. She was aware of her breast asymmetry with the right breast being bigger with greater skin sag and a resultant lower nipple position.

Under general anesthesia and through inframammary incisions, 400cc high profile breast implants were placed in a dual plane position. A right nipple lift was then performed through a half-moon shaped skin excision that was 1 cm at its central area.

Horizontal nipple asymmetry can and should be corrected at the time of breast augmentation with a nipple lift on the lower breast mound. Good implant sizing can overcome breast mound differences but will not on its own correct nipple level differences and may even make them worse. The superior areolar scar can heal quite well in most cases and does not create an aesthetic distraction.

Highlights:

  1. Breast asymmetry is the most common ‘deformity’ in prospective breast augmentation patients.
  2. Implants alone can not be counted on for correcting breast size or shape issues.
  3. A superior nipple lift on the more ‘saggy’ breast side during breast augmentation can help correct asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

June 22nd, 2017

The Model Cheek Implant (Malar-Arch Design) for the High Cheekbone Look

 

Cheek implants have been around for decades and have undergone an evolution of design changes. While initially developed as small oblong shapes to sit on top of the malar eminence, newer designs have incorporated the area under the malar eminence as well known as the submalar region. This has led to a variety of current shapes that include malar, submalar and combined malar-submalar (shell) styles, creating up to five different cheek implant options. (not to mention the various sizes of each style)

But careful analysis of the actual anatomy of the zygomatic complex (aka cheekbone) reveals that it does not match the shape of any current cheek implant. Structurally the cheekbone is fairly complex with a main body and three processes that articulate with other bones (frontal, temporal and maxillary) and has four borders. When the term ‘high cheekbones’ is used from an attractive and desirous facial beauty standpoint, this usually refers to more pronounced zygomatic arches or its posterior process. This causes a raised line along the sides of the face to appear which creates a distinct facial skeletal feature. This is often seen in fashion models in both men and women.

No performed cheek implant today truly creates the ‘model cheek’ look as they do not incorporate the zygomatic arch process as part of their design. To achieve this effect a special designed cheek implant is needed.  It can have various anterior shapes but the key element in the extended posterior zygomatic arch process. This extension can go back all the way to the temporal region if desired. Besides creating the raised line back from the cheek it also creates a smoother and more blended flow up across the cheeks  and back along the face rather than just a raised ‘bump’ over the cheekbone.

This malar-arch cheek implant design is placed in the standard intraoral fashion through the mouth. Subperiosteal dissection is carried way back along the zygomatic arch. As long as one is right on the bone there is no danger of injury to the frontal branch of the facial nerve that crosses in the tissues above the posterior zygomatic arch. The length of the tail of the implant can be shortened based on the patient’s anatomy and aesthetic goals. Because the implant has a long surface area contact with the bone in a more horizontal orientation the risks of intraoperative implant malposition and postoperative migration (if screw fixation is not used) is greatly reduced.

The model cheek implant is a malar-arch design that adds a skeletal coverage area not previously seen in any previous midface implant. It creates the high cheekbone look that many younger patients today seek in with contemporary fashion and beauty trends.

Dr. Barry Eppley

Indianapolis, Indiana

June 22nd, 2017

OR Snapshots – Rib Graft Tip Rhinoplasty

 

While many rhinoplasties are reductive in their overall reshaping effect, some require the addition of support or structure through the use of autologous tissue grafts. Most noses can be satisfactorily augmented or rebuilt through the use of septal, ear or combining septal and ear cartilage grafts. But when such local and regional cartilages harvest sites are depleted or inadequate for the amount of augmentation needed, the rib is the remaining ‘go to’ cartilage donor site.

Rib grafts offer an unlimited supply of cartilage graft material when it comes to what is needed in the nose. Regardless of where it is harvested (inframammary or subcostal incisions), the amount of donor material is more than adequate. Issues such as curved cartilage shapes (ribs are rarely perfectly straight) and whether full-thickness or in situ harvesting methods are used may pose some graft limitations But these are overcome by experienced harvesting techniques.

In the tip of the nose, rib grafts are needed when considerable tip lengthening or derotation changes are needed.  (rib graft tip rhinoplasty) Placing an L-shaped cartilage construct at the end of the nose has a powerful tip augmentation effect which is only limited by the ability of the skin to stretch over it and still have adequate perfusion after surgery.

Rib grafting to the nasal tip is often an onlay technique where the grafts are placed over the existing medial footplates and dome cartilages. A pocket is made under the columellar skin below the incision down to the anterior nasal spine into which one carved piece of the tip graft is placed. (vertical graft component) A lower dorsal-dome cartilage graft (horizontal component) is fashioned and placed on top of the existing dome cartilages to be united at 90 degrees to the columellar piece. Suturing the two rib grafts together creates the new tip defining point.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Custom Occipital Skull Implant Markers

 

Background: A flat back of head is one of the most common aesthetic skull problems that is treated. It is best augmented with a custom skull implant made from the patient’s 3D CT scan. This lessens dramatically the aesthetic risks of implant irregularities and edge transitions as well as asymmetry of the contours of the augmentation. There is a huge advantage to controlling the shape and thickness of the implant before surgery. This then leaves the role of the surgeon during surgery to ‘merely’ position it on the skull as it was designed.

The other major benefit to a custom implant that is flexible is that it can be inserted through a smaller scalp incision than that of the diameter of the implant. Every cm of scalp incision (or less thereof) can be of valuable aesthetic consequence. This also speaks to the value of a preformed implant whose shape and thickness can not be altered by the insertion process.

While a smaller scalp incision is of aesthetic benefit, it also severely limits a view of the implant’s position on the skull bone. Not seeing the circumference of the implant’s position on the skull bone can potentially create implant malposition. A curved implant on a curved bone surface under the compression of the overlying scalp can make it seem that just about any implant position is correct.

Case Study: This 57 year-old female had long been bothered by the flatness of the back of her head. (crown area or upper occipital region) Using a 3D CT scan, a custom occipital skull implant was designed to maximally augment the deficient skull area within the constraints of what the scalp stretch would allow.

Under general anesthesia and in the prone position, a 9cm long irregular scalp incision was made over the nuchal ridge. From this incision wide subperiosteal undermining was done with instruments up over the crown way into the top of the skull towards the forehead. The custom skull implants was inserted by folding the sides under creating a more narrow rolled tube. Once inserted the folded sides were unrolled and the implant flattened into the shape by which it was designed. It was then properly positioned by using the compass marker manufactured into the back edge of the implant to get both the midline positioning as well as having no right or left tilt. It was then secured with two small microscrews and the incision closed.

Most custom skull implants benefit in positioning with an embossed compass marker, regardless of what skull area they cover. The limited view of the implant with discrete scalp incisions requires visible registrations to aid in its orientation.

Highlights:

  1. A custom occipital skull implant is the most effective way to build up a flat back of the head.
  2. Proper  positioning of a skull implant in which the scalp incision. permits limited visibility requires a registration mark on the exposed part of the implant.
  3. A compass marker provides a 3D orientation method for skull implant positioning.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Older Maximum Breast Reduction

 

Background: Reduction of large breasts is one of the most common body contouring procedures in plastic surgery. It has been around in various forms for almost one hundred years. It is a uniformly successful procedure for reducing the back, neck and shoulder pain that typically accompanies large sagging breasts as well as positioning the breasts back up on the chest wall.

By the way it is designed every breast reduction procedure is also a breast lift. While a breast lift can be done without a breast reduction, the reverse is not true. A reduced amount of breast tissue means that the skin that contains it also must be less. The markings made on the skin before surgery is the breast lift part and is a very mathematical and precise part of the procedure. The reduction of the breast tissue is internal and is much more of an artistic technique rather than one that lies on measurements of angles and linear distances.

Breast reduction in older mature women. often has a slightly different flair to it. Women that have had large breasts all their life, and who have finally come to the point of wanting them smaller, usually want a more aggressive reduction. The need for symptomatic paint relief and the desire to look less matronly mandate that larger amounts of breast tissue be removed.

Case Study: This 65 year-old female had large breasts her whole life. (DD + cup size) She had three children and her breasts always ended up looking about the same afterwards albeit a bit more droopy. She was ‘over’ having large breasts and wanted the freedom in its clothing and exercise to have more freedom of choice.

Under general anesthesia an inferior pedicle breast reduction was performed with the removal of approximately 800 grams per side. Her nipple-arolear complex was raised 9 cms from a 30 cm length from the sternal notch to the nipple to a 21 cm length.

Older women are almost always more concerned about having a ‘maximal’ reduction procedure on their breasts than they are about having a fuller lifted shape. As  long as they sit much higher up on they chest wall with a more centered nipple with a low volume, they will enjoy the benefits of less to no musculoskeletal discomfort and the freedom should they so choose to even go without a bra.

Highlights:

  1. Breast reduction in older women is often a ‘maximum’ reduction and lift procedure.
  2. Getting reduced breast tissue back up on the chest wall is ultimately what causes a reduction in musculoskeletal symptoms.
  3. The inferior pedicle breast reduction technique offer a reliable and safe method for larger breast size reductions.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Increased Penile Show with Pubic Liposuction

 

While undesirable fat collections can occur anywhere in the body, even small amounts in the wrong place can have undesired effects on adjacent body structures. Such is the case with pubic mound lipodystrophies. The buried penis, also known as the hidden or concealed penis, is when some or all of the length of the penis is obscured by the size of the pubic fat pad. This creates the impression of a short or deficient penis even though its true length may be actually normal.

In the April 2017 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘Infrapubic Liposuction for Penile Length Augmentation in Patients with Infrapubic Adiposities’. In this clinical study ten (10) patients were treated by liposuction. All were under age 40 with two-thirds (6 out of 10) having various degrees of obesity. The volume of fat aspirate averaged around 500ccs. (range of 325cc to 850cc) The increase in flaccid penile length three months after surgery was 1.1cm. (14%) Patient satisfaction was very satisfied (30%), satisfied (50%) and no change or dissatisfied. (20%) No correlation was found between the obesity of the patient and their satisfaction with the outcome of the suprapubic mound reduction.

The use of ljposuction in the treatment of the full or fatty pubic mound is much more common in children and teens in conjunction with actual penile lengthening in the treatment of the buried penis. These young patients may or may not be normal weight for their height. Treatment of the buried penis in adults is usually associated, more times than not, with some degree of being overweight. It is therefore logical that reduction of the height of the suprapubic mound would improve penile show. This does not mean that the actual penis gets longer, just that more of its natural length is revealed.

This clinical study supports what other such studies have shown…that liposuction reduction of the pubic mound adds up to 1cm or more of penile exposure. It is important that men realize that this is 1 cm and not 1 inch of penile reveal. Mound size reduction is helpful but is not a true penile lengthening procedure.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Cleft Lip Revision with Buccal Fat Graft

 

Background: Repair of a primary cleft lip deformity is one of the common pediatric plastic surgery procedures performed in infants. Usually done around three to four months of age, its repair is usually done by the rotation-advancement technique. This well established cleft lip repair procedure works by derotating the shortened medial lip element and bringing in the lateral lip element in its wake. Once in alignment the lip vermilion is then debulked and put together for a smoother and more uniform red part of the lip.

But despite how good a cleft lip repair may look at 6 months or one year of life, the effects of growth and scarring/wound contracture are often not kind. Over time many well-executed cleft lip repairs will change in appearance. The most common changes are shortening of the philtral length, notching of the vermilion lower lip edge and mismatching of the vermilion-cutaneous border at the Cupid’s bow area. As a result the need for secondary cleft lip revisions is the norm rather than the exception.

While there are numerous detailed techniques in cleft lip revision, one of the major ones used is the correction of a notched vermilion and to improve its projection/fullness. Realignment  of the vermilion and mucosal V-Y advancements are useful secondary vermilion enhancement methods. One very effective method for improving vermilion full ness with a scar revision/realignment is a fat graft. Fat grafts not only bring in volume but healthy tissue as well.

Case Study: This 16 year-old female teenager was born with a right complete cleft lip and palate deformity. She had primary cleft lp and palate repairs as well as a secondary alveolar bone graft. As a teenager her initial cleft lip repair showed vertical philtral length shortening, an inverted V notch at the lower edge of the upper lip and lack of adequate projection/protrusion.

Under general anesthesia a V-Y mucosal advancement was done, rolling out the lip mucosa to help correct the inverted V notch deformity. To prevent its contraction with healing and to help add some lip volume a free fat graft was placed prior to its closure. The fat graft was harvested from the opposite buccal fat pad through an intraoral incision. Only a small piece of the buccal fat pad was needed. (much less than even a subtotal buccal lipectomy.

Many cleft lip revisions have a need for increased volume. Autologous fat is a logical soft tissue graft that can be incorporated into many cleft lip revisions. The buccal fad pad is both a regionally convenient and hardy fat source which can be harvested without scarring. The volume removed is minimal but still should be taken from the non-cleated side of the face since the buccal fat pad on the cleft is already slightly smaller in most cases.

Highlights:

  1. Very few primary cleft lip repairs ever do not need a secondary revision.
  2. One of the most common secondary cleft lip issues is a lack of vermilion volume.
  3. One source of adding additional volume is with the use of free fat grafts, specifically that from the buccal fat pad.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Silicone Testicle Implant Replacement

 

Background: The only viable replacement for a lost testicle is that of an implant. Placing an implant in the scrotal sac has a very low risk of any significant complications such as infection or a hematoma. This because the anatomy of the scrotum is fairly straightforward and the testicular replacement must merely provide a static volumetric substitution for the space previously occupied or would have been occupied by the normal testicle.

The aesthetic demands of a testicular implant is what represents the most common postoperative problems with them. Size discrepancies (usually too small), an implant that feels too firm and lack of implant mobility are the most common complaints with testicular implants. These have all been associated primarily with saline-filled implants whose hydrodyamic properties are not necessarily an ideal substitute for a more naturally solid soft tissue structure.

What is unique about the aesthetics of the testicle is that how it feels and moves about between the upper inner thighs is equally, if not more important, than that of its appearance. (scrotal symmetry) The scrotal sac ends up being partially compressed between clothing and the skin which creates awareness of how it feels. While the scrotum is a suspensory soft tissue envelope, this is not how it is primarily perceived. (we spent a lot more time in clothes than out of them)

Case Report: This 35 year-old male had a history of a left saline testicle implant being placed for a congenital undescended testicle. The implant felt too firm and had a visibly smaller size compared to the opposite normal right side.

Under general anesthesia and using the existing high scrotal scar, the implant pocket was opened  and the indwelling implant removed. A capsulotomy was performed to expand and lower the implant pocket. A solid soft testicle implant measuring 5.0 x 4.0cms was chosen as the replacement which appeared about 30% bigger in overall volume. Better scrotal symmetry was achieved with its placement and closure.

Sizing testicle implants can be challenging but almost always the size needs to be bigger than what one would think. Many patients often end up between two sizes and it is important to ask the patient before surgery if they would prefer to be a ‘little too small’ or a ‘little too big’.

The feel of a testicle implant is often very relevant and may supersede that of a size discrepancy. It is hard to get around the material feature that a saline implant just doesn’t feel normal, it almost always feels too firm particularly if it has been filled to its minimal volume or has any amount of overfill at all. Low durometer solid silicone implants always feel more natural as they replicate the compressibility of a normal testicle better

Case Highlights:

  1. Replacement of saline testicle implant with a solid silicone one results in a soft more natural feel.
  2. To accommodate a larger implant in the scrotal sac, a release of the scar tissue (capsulotomy) is usually needed.
  3. Sizing of the new implant is best done by measurements taken from the existing implant during surgery and choosing a new implant with larger dimensions

Dr. Barry Eppley

Indianapolis, Indiana

June 18th, 2017

A Clinical Outcome Study of Nasal Implants (Alloplastic Rhinoplasty)

 

There is an inevitable need in rhinoplasty surgery in some patients for augmentation. Whether it is for smaller defect corrections or for an overall major dorsocolumellar increase, volume addition to the nose is not infrequently needed. There is no question that cartilage grafting is the best tolerated form of nasal augmentation with the lowest risk of infection. But they are not perfect and cartilage grafts have their own issues from donor site harvesting, structural and shape constraints and an increased technical skill for their use.

As a result, the use of a variety of implant materials in the nose will always persist. Despite their often negative perception implants do have a role to play in the nose and any clinical series ion substantial volume and follow-up is always worthy of review.

In the April 2017 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases’. In this paper the authors  report on their experience in over 300 cases of nasal implants. It is important to distinguish what they mean by soft and firm nasal implants. The ‘soft’ nasal implants they used were synthetic polyester sheets (mersilene mesh) which is used for other surgical applications as its origins. These are sheets of monofilament fibers whose structure permits soft tissue ingrowth. These mesh implants were used in the tip, dorsal and side walls of the nose in varying thicknesses. Such soft implants were used in the majority of their cases. (87%, 269/311) The average implant thicknesses were 1.5mm or less. The firm implants were solid silicone L-shaped nasal implants. The thickness of these implants were 5mms or less. In some cases the tip of the nasal implant was covered by fascia or morselized cartilage. Such firm implants were used in the remainder of their cases. (13%, 42/311)

The infection rate in the soft implants occurred in 6% of cases (15 patients) Revisions for aesthetic purposes was done in 3% of the patients. (7 in number) Conversely no infections occurred with firm silicone implants. Aesthetic revisions were done in 7% of the cases. (3 in number)

The use of implants in the nose, known as alloplastic rhinoplasty, has its share of detractors. For some rhinoplasty surgeons the use of synthetic materials in the nose is never done while other surgeons use them routinely as is the case in this paper. Implants do have their unique set of advantages including volume stability, lack of the need for a donor site, versatility in shaping of the implant and often shorter operative times.

In this paper the authors show a very acceptable and low rate of implant infections as well as the need for revisions. In my opinion this was not due to the implant material but in how it was used. The key to their success is that they did not ask the implants to ‘do too much’. The implants usually had low thicknesses even in the solid silicone implant group. While one can get away with a lot of soft tissue stretching or even mucosal perforations with cartilage grafts, implants are much less tolerant of these soft tissue issues. Probably the greatest contribution this paper makes to the rhinoplasty literature is that implants can work fairly well in the nose when judiciously and selectively used.

Dr. Barry Eppley

Indianapolis, Indiana

June 18th, 2017

The Role of Custom Chin Implants

 

Alloplastic chin augmentation is the oldest facial implantation procedure. As a result, many different styles and sizes of chin implants have been used over the five decades of the procedure being performed. While in the vast majority of patients standard preformed chin implants work just fine, they do not always achieve the patient’s aesthetic lower facial reshaping goals. It is important to remember that current chin implants styles are based on historic patient’s aesthetic needs and surgeon experiences as well as what is economically feasible for the manufacturer. (they can’t produce endless styles of chin implants that end up having few commercial sales)

It is also relevant that today’s patients may have different aesthetic goals than that of what was popular ten or twenty tears ago. Patients are also becoming increasingly sophisticated as to the nuances of their facial aesthetics and, in some ways, are becoming more ‘3D’ in the desire for their facial changes. There is also the patient who has had a standard chin implant and is dissatisfied with the result due to shape issues.

As a result, there is an increasing role for custom chin implants. Even though the chin implant is the ‘simplest’ of all facial augmentation procedures that does not mean it is always easy to get a pleasing chin augmentation outcome. Contrary to popular perception the revision rates of chin implant surgery is not as low as most patients and surgeons believe. I have seen many patients who are on their second or third chin implant seeking an improved result.

Customizing a chin implant design can achieve several shape improvements over standard chin implants. First and foremost it can provide a horizontal projection versus width ratio that is not available in standard styles. Secondly, it can create a vertical lengthening increase with horizontal and transverse widths that is not currently available. Third, the wings of the implant can be designed to blend in better along the inferolateral borders of the lower jaw. Lastly, features such as a vertical chin cleft can be added.

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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