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Dr. Barry Eppley

Explore the worlds of cosmetic
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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.

May 30th, 2016

Surgical Correction of the Constricted Ear Deformity

 

One of the major types of congenital ear deformities is that of the constricted ear. It is estimated that it represents about 10% of all congenital ear deformities. It is a variable ear deformity that has been described by multiple classification systems (e.g. Tanzer, Cosman, Ngata) with associated surgical strategies based on its classification. The numerous classification systems can be confusing and it is not easy to always define what type of surgery is best for the variable presentations in which the constricted ear is seen.

Constricted Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley Indianapolis Constricted Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisIn the May 2016 issue of Plastic and Reconstructive Surgery, a paper was published entitled ‘Classification and Algorithmic Management of Constricted Ear: A 22-Year Experience’. Over 160 ears that had a lidded helix, compressed scapha and triangular fossa and an overall cuplike appearance were used as the clinical material for the study. The authors classification system uses a antihelical tubing test and a scapha-helix push test. By these two methods four types of contricted ear are identified. Type 1 constricted ears can be treated by an antihelical tubing procedure using horizontal mattress sutures placed on the backside of the ear. A type 2 constricted ear was treated by  tumbling concha-cartilage flap combined with a mastoid hitch suture. In type 3 constricted ears an antihelical wrapping technique using a free floating rib cartilage graft was used. In type 4 constricted ears where a shortage of helix exists, a helical expansion technique using a rib graft and preauricular and scapha skin flaps was used.

Based on their experience the authors have evolved to the following concepts for the constricted ear. First, waiting to age 12 or older allows for better results. Second, the existing cartilage framework was not sectioned but rolled and grafted to prevent unnatural shapes. Third, rib grafts are better than ear cartilage grafts for helical expansion. Lastly, the protruding part of the constricted ear is often overlooked and needs to be corrected by mattress sutures and/or mastoid hitch sutures.

The constricted ear and microtia have some overlap in their features. What separates them surgically is that in the constricted ear the existing cartilage framework is maintained and cartilage and soft tissue flaps are added to it. In microtia, the existing framework is unusable and has to be replaced. This paper provides an effective surgical strategy for the constricted ear that allows for a single stage correction without removal of any of the existing ear framework

Dr. Barry Eppley

Indianapolis, Indiana

May 29th, 2016

Volume Comparison of Chin Implants and Injectable Fillers

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is a common aesthetic facial reshaping procedure that is second only to rhinoplasty. It has been traditionally performed by the placement of a preformed implant. While many different chin implant styles have been used over the years, the basic concept of an alloplastic chin augmentation is the same.

The emergence of injectable methods for facial augmentation using a variety of injectable fillers and fat has now become an accepted treatment approach for chin augmentation. While no injectable material offers an assured and permanent outcome as that of an implant for chin augmentation, it does provide an opportunity for patients to non-surgically ‘wear’ the result for awhile to determine if it suits them.

An interesting but relevant issue when using injectable fillers for chin augmentation is how do they compare volumetrically. To create an injectable chin augmentation effect, what volume of injectable filler is needed to compare to what a chin implant does. It is not a fair comparison if one is ‘testing’ an injectable filler and the volume injected does not equal what that of the effect that a chin implant does.

Volume Displacement of Facial Implants Dr Barry Eppley Indianapolisextended-anatomical-chin-implantComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and all facial implants do) Using the most commonly used extended anatomic chin implants (Implantech) of small, medium, large and extra large, their weights in grams and volume displacement were as follows:

Small Chin Implant        2.1 grams     1.3cc

Medium Chin Implant   2.7 grams      1.7cc

Large Chin Implant      3.4 grams     2.2cc

X Large Chin Implant  4.0 grams     2.7cc

The volume displacement of all injectable fillers is on the syringe so the comparison to chin implantsis straightforward. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be less than even a small chin implant. A small anatomic chin implant more favorably compares to 1.5cc of Radiesse. Larger chin augmentation effects requires up to 3ccs of injectable filler regardless of the type.

There are other variables that affect how any of these materials create an external facial augmentation effect. The most significant would be how well does the material push on the overlying soft tissues or push off of the bone to create their effect. This is known as G Prime Force or their elastic modulus. It is quite clear that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) Therefore it is probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

Dr. Barry Eppley

Indianapolis, Indiana

May 29th, 2016

The Composite Nasal Implant in Asian Rhinoplasty

 

In Asian rhinoplasty, one of the principle elements of its treatment is dorsal augmentation. This can be done using a silicone nasal implant or the autologous option can be done using a rib graft. Because of its ease of use and that it spares the patient a donor site, silicone nasal implants are widely used around the world particularly in many Asian countries.

Despite the effectiveness of its use, silicone nasal implants are a synthetic material. As a result, they do have a well known potential for complications including infection and migration. The very feature that makes them easy to use (smooth and non-adherent surface) is exactly what can lead to its potential complications.

Composite ePTFE coated Nasal Implant Dr Barry Eppley IndianapolisIn the Published-Ahead-Of Print section of the May 2016 issue of the Annals of Plastic Surgery, an article appeared entitled ‘Silicone-Polytetrafluoroethylene Composite Implants for Asian Rhinoplasty’. In this paper the authors used this composite nasal implant in 177 patients over a three-year period. One-third (63) of these were placed in primary rhinoplasties while roughly two-thirds (114) were placed in secondary rhinoplasty surgery. The majority of the rhinoplasty patients were women. The composite nasal implants were 1.5 to 5 mm thick and 3.8 to 4.5 cm long. The implants did not extend onto the nasal tip which was treated in every case with cartilage grafts.

Over the three year study period, there was a 10% incidence of complications including deviation, persistent redness, infection (1%) and  dissatisfaction with the height of the dorsal augmentation. This lead to a 9% revision rate for corrections. No significant differences in these complications occurred between primary and secondary rhinoplasty.

A composite nasal implant places a 0.3mm layer of PTFE (Gore-Tex) on the silicone surface. Given that Gore-Tex implants have a history of tissue ingrowth into their surface,  this would theoretically make them more biocompatible and less prone to complications. To date the theoretical benefits to composite nasal implants have not been substantiated in a large clinical study until this report.

While no synthetic material implanted in the face will ever be free of complications, the addition of a PTFE coating onto a nasal implant appears to offer some clinical advantages over non-coated silicone nasal implants. Whether their long-term results will be more favorable than uncoated implants in rhinoplasty can not be determined from this study.

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2016

Case Study – Bone Cement Cranioplasty

 

Background: The external shape of the head is a direct reflection of the form of the skull underneath it. While skulls can have various sizes and are made up of multiple cranial bones, a smooth and convex shape is desired no matter from what angle it is viewed.

Men make up a greater portion of skull reshaping patients than women. This is a direct result of exposed scalp surfaces from men who have shaved their head or have little hair density or length to cover it. Women can better camouflage skull irregularities because of their usually better hair density and growth.

Prior skull surgery or cranioplasty efforts can leave a skull shape that is asymmetric or irregular. While the skull surface may appear smooth at the time of surgery, healing and scalp adaptation may eventually reveal even the most minor skill irregularities.

Case Study: This 45 year-old male presented with a desire to improve the shape of his head. He had a history of prior skull surgery and cranioplasty efforts, of which the initial origin of these efforts remained unclear. He reported that ‘bone cements’ had been used in the past.

Under general anesthesia and through his existing coronal scalp incision from ear to ear, his entire skull surface was exposed. There was a form of bone cement (which appeared to be Kryptonite from my experience) at various locations on his skull. Its application was irregular and not smoothly applied. A handpiece and burr was used to reduce and smooth out all existing bone cement areas. Application of new bone cement (PMMA) was used to fill in any depressed skull areas.

Revision Skull Reshaping result front view Dr Barry Eppley IndianapolisRevision Skull Reshaping result back viewHis results six months later shows a much smoother and convex skull shape. His case illustrates that no matter how thick the scalp may appear any irregularities of the skull will eventually be seen. Applications of bone cements on the skull must be smooth and feathered into the surrounding bone to avoid visible irregularities.

Highlights:

1) The shape of the head should be smooth and convex from all viewing angles.

2) Many skull contour irregularities can be satisfactorily treated by the application of bone cements

3) There are different types of bone cements used in cranioplasty which differ in material and cost but not in effect.

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2016

Case Study – Bingo Arm Liposuction

 

Background: Fat collects in the extremities just about as well as in the trunk region in many patients. Unlike abdominal fat, for example, fat in the extremities can be very difficult to reduce as it is often less responsive to diet and exercise. While extreme amounts of weight loss (e.g., gastric bypass) can reduce extremity fat, many patients do not need or will undergo these extreme amounts of weight loss.

Excess fat on the arms typically refers to undesired fullness on the back of the upper arms. The triceps area is the most bothersome area of excess arm fat because it hangs down when the arm is raised. A fatty back of the arm will jiggle when the arm is moved back and forth. This has led to the term ‘bingo arm’ or ‘bingo wing’. According to the Urban Dictionary, bingo arms comes from the observation of the excitement of winning bingo at senior’s night where one waves their arms back and forth creating a back and forth movement of the back of the arms.

Case Study: This 44 year-old female was bothered by the size of the back of her arms. While she was not excessively oveweight, the fullness on the back of he arms was aesthetically disturbing. She caller her arms ‘Bingo Arms’ which was the first time I had ever heard this arm issue so described.

Bingo Arm Liposuction intraop Dr Barry Eppley IndianapolisUnder general anesthesia and through small stab incisions right above the elbow as well as on the back side of the armpit, two-directional power-assisted liposuction (PAL was performed using  3mm cannula. A total of 225cc of fat aspirate was removed from each arm.

Bingo Arm Liposuction result left arm Dr Barry Eppley IndianapolisHer results at three months after surgery showed substantial improvement in reduction of the size of the back of arms. While it did not make her arms small, liposuction did eliminate much of the upper arm jiggle.

Bingo arm liposuction can be very effective in the properly selected patient. There is a limit as to how much fat can be removed from the arms and how well the skin will shrink and tighten. When the amount of skin becomes more significant than in this patient, an excisional armlift may be a better treatment choice.

While many different types of liposuction exist, none have proven to produce consistently better results than other. Power-assisted liposuction (PAL) in my hands remains more effective than traditional liposuction particularly in smaller confined areas like the back of the arm. Allowing the mechanized tip of the cannula to do the work, as opposed to the ‘elbow grease’ of the surgeon, makes for a more effective effort. A mechanized cannula tip can move back and forth far faster and more frequently than what    a human can do. (thousands of time per minute as opposed to dozens of times)

Highlights:

1) Liposuction can be performed safely on the arms. (bingo arm liposuction)

2) The back of the arms (triceps area) offers the greatest depot of fat for liposuction extraction in most patients.

3) Power-assisted liposuction (PAL) provides an effective method of arm fat extraction.

Dr. Barry Eppley

Indianapolis, Indiana

May 28th, 2016

Case Study – Anterior Rib Removals for Vertical Waistline Lengthening

 

Background: Modifications of the ribcage can be done for a variety of body contouring reasons. Most commonly posterior rib removals are done for anatomic waistline narrowing. By removing the ends of ribs 10, 11 and 12, the width of the waistline can be narrowed in width by removing the ‘obstructions’. This is ribcage modification done for a transverse or width body improvement.

anterior rib removalsBut above the level of the free floating ribs, the ribcage is a circumferential structure. Underneath the breasts/chest is the bottom end of the ribcage known as the subcostal region. It consists mainly of ribs 7, 8 and 9. In some patients these bottom ribs may stick out or protrude creating an unaesthetic bulge.

Anterior rib removals, like that of posterior rib removals, can be done for aesthetic trunk modification. The most direct approach to them is through a small subcostal incision over their lower portion. By removing or shaving the lower subcostal ribs the protrusion of the ribcage can be reduced. Such modifications can also increase the vertical length of the waistline by increasing the distance between the lower end of the ribcage and the hips.

Case Study: This young transgender female was bothered by a subcostal protrusion of her ribs. She would rather have a small subcostal scar than ribs that stick out.

Anterior Rib Removals surgical technique Dr Barry Eppley IndianapolisAnterior Rib Removals surgical technique 2 Dr Barry Eppley IndianapolisUnder general anesthesia and through a 4.5cm central subcostal incision, the lower ribs were accessed by splitting the overlying rectus muscle. The cartilaginous portions of ribs 8 and 9 were removed from the sternum out laterally to their bony junction. Rib #7 was significantly reduced by shaving its lower edge.

Anterior Rib Removals result intraop from one side Dr Barry Eppley IndianapolisThe change in the lower ribcage protrusion was immediately apparent during surgery when the treated side was compared to the yet to be treated side. The flow from the breasts into the abdomen was smooth and more concave.

Anterior Rib Removals for Anterior Rib Protrusions intraop result Dr Barry Eppley IndianapolisAnterior rib protrusions are more of a concern for women as they produce a noticeable bulge at the upper abdomen. Such a hard prominence also vertically shortens the waistline between the lower end of the ribcage and the hips.

Rib removals can be done as either a posterior, anterior or combined technique. These modifications are done at the lower end of the front and back part of the ribcage for different body contouring effects. Because they are at the bottom of the ribcage such rib removals are associated with a very low risk of any significant problems. The lower end of the pleura of the lungs is close by and knowledge of its location is paramount for safe rib removal surgery.

Highlights:

1) Vertical waistline lengthening involves anterior rib removals.

2) Anterior rib removals are also useful to reduce ribs that stick out at the bottom of the ribcage.

3) Anterior rib removals are done through a small subcostal incision or can be done through a full tummy tuck approach.

Dr. Barry Eppley

Indianapolis, Indiana

May 26th, 2016

Case Study – The Bumpit Custom Skull Implant

 

Background: The height of the head can be an important aesthetic issue for some women. Flat or low skull height over the crown area can be seen as an undesirable physical feature. Women will often try to camouflage the lack of crown height by altering their hairstyle with ‘hair heightening’. While this can be effective, it is time consuming and tedious. And not all women have enough hair density to do this adequately.

Bumpit Dr Barry Eppley IndianapolisThis aesthetic skull height concern is illustrated by the invention known as the Bumpit. This semicircular plastic insert on the scalp allows the hair to be ‘volumized’ which makes the height of the head appear taller. While claimed as being a silly and useless invention, the women that use it and find it effective probably do not see it as such.

A surgical and invasive method to create a partial Bumpit effect is the use of a custom skull implant. As a one stage procedure it may allow in some cases for the crown skull height to be augmented from 8 to 12mms. (which is roughly half of the typical Bumpit height of about 25mms) But its effects covers a broader surface area of the skull to blend into the sides of the head with a smooth tapered transition.

Custom Skull Implant Dr Barry Eppley IndianapolisCase Study: This 35 year-old female had been bothered by her flat head. She spent a lot of time fixing her hair to hide it and would not go out without a hat when she didn’t have the time to fix her hair. She finally decided to seek a surgical solution. Using a 3D CT scan a custom skull implant was designed to increase her skull height by 9mms at the most central height of the crown

Custom Skull Implant with compass marking Dr Barry Eppley IndianapolisCustom Skull Implant insertion and placement Dr Barry Eppley IndianapolisUnder general anesthesia and in the beach chair position, a limited coronal scalp incision was made.Wide subperiosteal undermining that went just beyond the boundaries of the planned implant size, the pocket was developed. The custom skull implant was opened and muttiple 4mm perfusion holes were placed using a dermal punch. The implant was then inserted and oriented into place using the ‘compass’ markings in the implant. A two later was done for closing the scalp up over the implant. No drain was used

Bumpit Custom Skiull Implant result front view Dr Barry Eppley IndianapolisBumpit Custom Skull Implant result back view Dr Barry Eppley IndianapolisBumpit Custom Skull Implant result side view Dr Barry Eppley IndianapolisThe skull height augmentation was clearly evident and sufficient to satisfy the patient. A one stage custom skull implant can safely create an additional 1 cm of height using a limited scalp incision approach. While greater scalp laxity can be obtained with a full coronal incision from ear to ear, that scar tradeoff for many women may not be worth it. If one needs more than 1 cm of additional skull height, consideration has to be given to a first stage scalp tissue expander,

Highlights:

1) Some women may not have adequate height to the crown of their head for their aesthetic desire.

2) The Bumpit Custom Skull Implant is designed to create additional crown skull height from being placed under the scalp.

3) The extent of  ‘scalp heightening’ that can be achieved with a custom skull implant is determined by the extent of scalp stretch that can safely cover the expanded bone height underneath it.

Dr. Barry Eppley

May 25th, 2016

Case Study – Female Calf Augmentation

 

chicken leg female calf augmentation Dr Barry Eppley IndianapolisBackground: A disproportionate lower leg size compared to the body, or even to the thighs, is often given the name ‘chicken legs’ This obviously refers to the very small size of the legs that most birds have compared to their bodies. While such a leg size is of no concern to birds, it can be quite disconcerting to some women. For those so afflicted, it is a source of embarrassment and may even prevent them from wearing any clothing that exposes their legs above the ankles.

A thin lower leg is usually due to small calf muscles. Underdeveloped calf muscles will make the lower leg between the knee and ankles look like a near straight pole without upper muscular bulging or shape. While there are two calf muscles per leg, both inner and outer gastrocnemius muscle are usually small. To make a visible size increase, all four heads or muscle bellies of the calfs need to be augmented.

Case Study: This 47 year-old female had been bothered about the small size of her lower legs for years. Because of her small calfs she would not wear shorts, dresses or any clothing that revealed her lower legs.

Calf Implant incisions Dr Barry Eppley IndianapolisCalf Implant subfascial location Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, 3.5 cm long inner and outer skin incisions were made in a popliteal skin crease above each calf muscle head. Through these incisions a subfascial pocket was developed on top of the gastrocnemius muscles. Small soft silicone calf implants were placed over each muscle head with two implants for each leg. (15cms long, 5cms wide and 1.5 cms thick)

Female Calf Augmentation result front Dr Barry Eppley Indianapolis viewFemale Calf Augmentation result back view Dr Barry Eppley IndianapolisFemale Calf Augmentation result raised back view Dr Barry Eppley IndianapolisFor many female calf augmentation patients, a four implant approach is needed. The goal is to make the overall calf size bigger without one side of the calf being disproportionate to the other side. By placing roughly 75cc implants on each muscle belly, or 150cc additional volume per leg, the calf is increased in size and still appears natural. For a small petite female these calf implants are appropriate. For larger female medium size calf implants (135cc per implant) may be needed.

Highlights:

1) Females with ‘chicken legs’ had small medial and lateral gastrocnemius muscles.

2) A four calf implant calf procedure is needed to treat the thin lower legs in female calf augmentation.

3) Four small incisions behind the knees is needed to insert subfascial calf implants.

Dr. Barry Eppley

Indianapolis, Indiana

May 24th, 2016

Double Eyelid Surgery with Epicanthoplasty

 

Double Eyelid Surgery Dr Barry Eppley IndianapolisIn Asian blepharoplasty, more commonly known as double eyelid surgery, the influence of the fold at the inner eye (epicanthus) can affect the aesthetic outcome. As a result many double eyelid surgeries are combined with a medial epicanthoplasty for an improved aesthetic appearance. While the epicanthus is a small structure, there is a large number of operations described for its correction. There does not appear to be a universally agreed upon method for the epicanthoplasty which suggests that all of them have some downside.

Z-Epicanthoplasty Dr Barry Eppley IndianapolisHistorically, some surgeons have avoided epicanthoplasty because of the fear of visible scar formation at the inner eye. But the Z-epicanthoplasty has proven to be a safe and effective technique for eliminating the epicanthal fold during double-eyelid operations without problematic scarring at the medial canthal area. They are numerous small variations of the Z-epicanthoplasty most of which focus on  hiding the scar line in the inner cants area.

In the January 2016 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘A Modified Method Combining Z-Epicanthoplasty and Blepharoplasty to Develop Out-Fold Type Double Eyelids’. In this paper the authors describes his technique for combining double eyelid surgery with a Z-epicanthoplasty in over 1100 women. The goals of the surgery was to create a parallel double eyelid fold with an exposed inner canthus and lacrimal caruncle. The upper eyelid incision is carried out to the new inner canthus location and the skin excised. The muscle fibers that adhere to the inner canthal ligament are severed to release any tension on the epicanthal skin flap. A small z-plasty is then performed on the inner canthal skin flaps. The revision rate was eight patients. (less than 1%)

Double Eyelid Surgery and Lower Eyelid Love Band Surgery Dr Barry Eppley IndianapolisThe Asian upper eyelid has a characteristic single fold with an epicanthus and saggy skin. When an epicanthus is not present, a double eyelid surgery alone can suffice. But with an  epicanthal fold present, double eyelid surgery will create a short and narrow double fold appearance. Thus combining double eyelid surgery with an epcanthoplasty is now common practice. This allows for a smooth connection between the double fold eyelid and the inner canthus. The goal of the Z-epicanthoplasty is to relieve the tension on the medial cantonal area which contributes to the epicanthal fold being present and prevent any adverse scarring in this highly visible area.

Dr. Barry Eppley

Indianapolis, Indiana

May 23rd, 2016

First U.S. Penis Transplant

The first U.S. penis transplant was performed in Boston on May 8 and 9th by a team lead by a plastic surgeon. This is the third such penis transplant in the world. The 64 year-old male patient had his penis previously removed due to cancer. The operation took 15 hours over two days with the penile transplant coming from a deceased donor. The transplant surgery was part of a research program whose ultimate goal is to aid combat veterans with significant pelvic injuries as well as those men who have had penile resection due to cancer and penile amputations due to trauma.

Like all organ transplant surgeries, they are a marvel and plastic surgery has been at the leading edge of many of them for decades. While face transplants have gotten the most attention over the past few years, it is a far more complex type of tissue transplantation than that of a solid organ like the penis.

penile anatomyBut a penis transplant is still a challenge and this single operation belies the work that lead up to it. The hospital team spent several years preparing for the penile transplant which involved a lot of cadaver work to learn the intricate details of the anatomy as well as becoming proficient at harvesting a penis from a donor. Like so many things in life, a  single event if it is to be successful comes with a lot of preparation. Every new type of tissue transplant has required thousands of hours of preparation for the actual event. While microsurgery and reattaching blood vessels and nerves has been around for over 25 years, performing it on a new organ still requites a lot of forethought.

Plastic surgery continues to develop new techniques for reconstructive and aesthetic surgery. What will be learned for performing a pioneering surgery like penis transplants will one day translate into other more everyday surgical techniques. That has been the history of plastic surgery over the past 100 years.

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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