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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.

March 28th, 2017

Case Study – Wider Eye Blepharoplasty

 

Background: The desire for wider or more open eyes to improve one’s expression is not uncommon. Most of the people who seek such eye surgery have an abnormal eye appearance known as ptosis. This is where the upper eyelid hangs down lower than normal and covers up some of the iris or the colored part of the eye. The position often gets lower later on in the day as the eyelid muscles get more tired. Technically the upper eyelid margin should fall no lower on the iris than about 1mm. Anything lower gives the eye a tired or sleepy appearance.

Surgical repair of eyelid ptosis is well known and the exact surgical treatment depends on how much ptosis exists and its cause. Surgical techniques include levator resection, muller muscle resection and a frontalis sling procedure.

But a few select patients do not have true eyelid ptosis or it is very minor but still want a more open eye appearance. This raises the question of whether a ptosis like upper eyelid procedure can be performed on a normal eyelid without ptosis. Technically the procedure is the same even if the eyelid has a normal position. The more relevant question is whether by raising up a normal upper eyelid margin if this will have any negative effect on lid competency and adequate globe lubrication. (incomplete lid closure can create eye dryness)

Case Study: This 21 year-old female felt her eyes were not open enough. She felt her upper eyelids were too low and wanted them more wide open. She did have about 2mms of ptosis and a long upper eyelid vertical skin distance.

Under general anesthesia she had an ptosis repair blepharoplasty procedure done through an upper eyelid skin crease. Five levator-tarsal sutures were placed to raise the upper eyelid margin. Under general anesthesia this was more challenging as no dynamic eyelid motion could be done.

Wider Eye Blepharoplasties result Dr Barry Eppley IndianapolisHer after surgery results showed better elevation of the central part of her upper eyelid with increased iris exposure. She had no eye dryness issues.

Creating more wide open eyes usually involves the treatment of ptosis whether the patient recognizes they have this eyelid condition or not. As long as the upper eyelid margin does not create a scleral gap as a result of the ptosis repair there is no risk of eye dryness or creating an unusual eye appearance. (startled) Wider eye surgery involves increasing the vertical distance between the eyelids and is a form of ptosis repair to do so.

Highlights:

  1. Ptosis repair is generally reserved for use in patients that have actual upper eyelid ptosis.
  2. A wider open eye in the vertical dimension can be created using a ptosis repair blepharoplasty technique. (levator-tarsal suture fixation)
  3. The upper lid margin should sit no higher than the top of the iris.

Dr. Barry Eppley

Indianapolis, Indiana

March 26th, 2017

Case Study – Posterior Approach to Webbed Neck Correction

 

Background: A webbed neck, also known as a ptergyium colli, presents as wing-like skin extensions around the sides of the neck that extend down to the shoulders. One of its classic signs is that the occipital hairline follows down along the webs creating an m- or inverted v-shape to the hairline from the back. Significant neck webs are always syndromic and have well known associations with Turner’s, Noonan’s or Klippel-Feil syndromes.

But neck webbing is not always associated with a specific syndrome and I have seen numerous webbed neck patients that do not have any syndromic association or any other bodily symptoms. Their neck webbing appears to be an isolated finding or possibly they have mosaic Turner syndrome (absence of X chromosome in some cells) which results in milder symptoms than other types of the disorder.

In the treatment of neck webbing, the classic teaching is that the only effective treatment method is the use of Z-plasties along the line of the neck webs. While this is effective the Z-plasty scars would not be viewed as good tradeoff for the neck webs. I have never performed Z-plasties for neck webbing and never would. The scars are simply not acceptable particularly in milder forms of neck webbing.

Case Study: This middle-aged female presented with mild but visible neck webbing that she had her entire life. She did not have Turner’s or any other known syndrome and she was otherwise normal in every aspect of her physical and sexual development.

Webbed Neck Correction intraopWebbed Neck Correction intraop 2 Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a diamond-shaped ellipse of skin was removed with its two horizontal points oriented along a line drawn between the twos sides of the neck webs that would produce the greatest inward movement. The skin flaps were then undermined out to the webs bilaterally and the skin released from the fascia. Midline fascial plication was then done withu strong permanent sutures. The skin was was then closed in multiple layers, closing the diamond-shaped excision into a vertical linear closure.

JV Webbed Neck Correction result front view Dr Barry Eppley IndianapolisJV Webbed Neck Correction result back view Dr Barry Eppley IndianapolisHer one week after surgery results showed good improvement with the side profile of the neck being more vertical and not oriented obliquely outward. The early healing of the posterior neck scar line at suture removal showed a likely favorable outcome.

The old concept of treating neck webbing by Z-plasties should be abandoned for a posterior midline approach using skin excision and fascial release and plication. While this approach also creates a scar , it is placed in a location that has no aesthetic liabilities even if the scar widens.

Highlights:

  1. Webbed neck deformities are most commonly associated with Turner’s syndrome but smaller webbed necks can occur in isolation.
  2. Webbed neck correction depends on both skin excision and fascial plication on the back of the neck.
  3. Correction of the webbed neck results in a vertical scar at the bottom of the occipital hairline.

Dr. Barry Eppley

Indianapolis, Indiana

March 26th, 2017

World of Plastic Surgery – China

 

Plastic Surgery in China Dr Barry Eppley indianapolisChina Plastic Surgery Dr Barry Eppley IndianapolisLocated in East Asia, China is the world’s most populous country with a population close to 1.4 billion. It also has the world’s second largest land mass of just under 4 million square miles. It is composed of 22 provinces as well as has control over Hong Kong, Macau and essentially Taiwan. It has multiple large urban areas including Shanghai, Beijing, Guangzhou, Chongquip, Shenzhen, Tianjin and Hong Kong. Unlike the U.S which is bicoastal, China has only one long coast at its eastern side. A disproportionate amount of the population lies along this eastern region.

While China is a communist country with the central seat of power in Beijing, it looks and feels anything like that on the inside. While China may once have been an isolated country that was far behind the rest of the world, those days are long over. China is both modern and well organized and its tremendous wealth can be appreciated in its impressive infrastructure. Many areas of China are quite affluent and this can nowhere be more appreciated than in its two biggest cities, Shanghai and Beijing.

It should be no surprise that plastic surgery is both needed and thrives in a country with over a billion people. The amount of reconstructive surgery performed and is needed far outstrips the thousands of plastic surgeons that exist in the country. But it may surprise many as to how prevalent the aesthetic plastic surgery industry is. While many Chinese plastic surgeons perform cosmetic surgery, dedicated aesthetic hospitals exist. (a phenomenon not seen at this advanced level even in the U.S) These are not just a hospital name given to a small surgery center to sound impressive, they are true smaller hospitals with large square footages and full aesthetic services that boogle the mind of any U.S. plastic surgeon.

Nanjing China mapNanjing China CityOne example is the Huamei Aesthetic Hospital located in Nanjing China. Nanjing is an impressive Chinese city with a long rich history, having served as the capital city during many different dynasties. Known in the past as Nanking or Nankin it is located along the lower Yangtze river with a population of over 8 million people and the second largest city in the east China region.

Nanjing China Huamei Aesthetic Hospital Dr Barry Eppley IndianapolisHuamei Aesthetic Hospital Nanjing China front desk Dr Barry Eppley IndianapolisThe Huamei Aesthetic Hospital it is one of the most influential private hospitals in Jiangsu Province. It is also the East China Eye and Nose Plastic Surgery Research Institute. It is truly a hospital with four floors divided into multiple dedicated treatment areas. These include large treatment areas dedicated to skin rejuvenation, hair removal, hair transplantation, dentistry (teeth alignment, whitening, veneers), injectable Botox and filler treatments, non-invasive body contouring as well as plastic surgery with multiple operating rooms, recovery and hospital stay rooms.

Huamei Aesthetic Hospital Nanjing China Dr Barry Eppley and Chinese Plastic SurgeonsThe Huamei Aesthetic Hospital provides plastic surgery procedures that would be considered very typical for the Asian patient. These include double eyelid surgery, augmentation rhinoplasty, jawline reduction/reshaping, breast augmentation and liposuction. Most of the patients are younger and the aesthetic surgery would be considered more face and body reshaping rather than anti-aging surgery. (which reflects both how the Asian patient ages and recent cultural trends) The Chinese plastic surgeons who work there are employed by the hospital, are usually young, and often only perform one specific procedure.(e.g, rhinoplasty) This allows them to develop both expertise and efficiency in the surgery, which permits higher numbers of patients to be treated and, theoretically, with a lower rate of complications. The number of surgeries performed and the volume of patients treated per day is staggering by U.S. plastic surgery standards. (and probably anywhere else in the world)

The scope of proportions in China, for anything you can think of, far eclipses what happens here in the U.S. It is a fact of just sheer numbers. This is no different in aesthetic plastic surgery. The Huamei Aesthetic Hospital in Nanjing is an example of the Chinese applying a business approach to the concept of an elective service. They are experts at dealing with large numbers of people in an efficient manner.

Jiangsu Province Hospital Nanjing China 2Jiangsu Province Hospital Nanjing ChinaDepartment of Plastic Surgery Jiangsu Pprovince Hospital Dr Barry Eppley Indianapolis In the same city is the Jiangsu Province Hospital. It was established in 1954 and is a 3A Grade Hospital in China. It is a comprehensive public hospital which integrated traditional Chinese and Western Medicine. It has 2,500 beds which are always filled. It sees an average of 20,000 outpatients per day. The Department of Plastic Surgery was established just twelve years ago and has grown impressively under the leadership of Professor Jinlong Huang. It has its own dedicated building with multiple floors. Each plastic surgeon there sees an average of 75 patients per day with over 100 reconstructive surgeries performed collectively per week. Unlike aesthetic surgery, reconstructive plastic surgery in China is mainly provided in public hospitals. These numbers are even more staggering as the cases of congenital birth defects, traumatic injuries and cancer reconstruction in China are many fold higher than in the U.S.

Dr. Barry Eppley

Indianapolis, Indiana

March 25th, 2017

Jaw Angle Deformity after Sagittal Split Osteotomy

 

sagittal split mandibuar osteotomyThe sagittal split mandibular ramus osteotomy (SSRO) is the most commonly performed osteotomy of the mandible. It is done to either move the lower jaw and its attached teeth either forward or back to correct dentoalveolar deformities and bring the teeth into a better interdigitating relationship. It is a very cleverly designed osteotomy that splits the ramus of the mandible in a sagittal dimension into inner and outer cortical halves. One of the most important maneuvers during its execution is to avoid injuring the inferior alveolar nerve that runs through the bone.

In looking at diagrams of the bone put back together and even early after surgery x-rays, there is a smooth inferior border between the proximal and distal segments. One of the key elements during surgery is to ensure there is good alignment along the inferior border in most cases.

Jawline Irregularities after Sagittal Split Osteotomies Dr Barry Eppley IndianapolisDespite this bony alignment during surgery it is not rare that long-term healing leads to notching along the once smooth inferior border. Thus undoubtably occurs due to some bone resorption from partial devascularization to the outer half of the bone. The outer bone segment has had the masseter muscle stripped off during the procedure, and in conjunction it being split away from its inner half, it has become partially like a free bone graft near the anterior vertical bone cut.

Such notching along the inferior border can be an insignificant issue or can cause  a visible external deformity. I have observed it numerous times in the creation of custom jawline implants and has often been a reason for the implant to recreate a visible and well defined jaw angle shape. Between creating better jaw angle shape and improving the notching the lies anterior to it, a custom implant design may be need in any cases.

Dr. Barry Eppley

Indianapolis, Indiana

March 25th, 2017

Great Auricular Nerve Branches in Facelift Surgery

 

Greater Auricular Nerve in Facelift SurgeryThe most common injury that occurs from a facelift is to the greater auricular nerve. This is a large sensory nerve comprised of fibers from C2 and C3 spinal nerves that supplies sensation to the ear and the skin over the parotid gland and mastoid process. It is located across of the sternocleidomastoid muscle where it ascends parotid gland where it bifurcates into anterior and posterior branches. It is this location of the nerve that makes it susceptible to injury during the raising of the facelift skin flap.

The classic teaching in facelift surgery to avoid injury to the greater auricular nerve is to identify the McKinney point. This point represents the location of the nerve trunk which is 6.5 cms below the ear canal on the sternocleidomastoid muscle. Further delineation of the nerve distribution was described by Ozturk with a 30 degree angle from the Frankfort horizontal plane which outlines the region of nerve distribution. Staying right under the skin and above the fascia over this area will avoid inadvertent nerve injury.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery an article appeared entitled ‘What Is The Lobular Branch of the Great Auricular Nerve? Anatomical Description and Significance in Rhytidectomy’. In fifty cadaver dissection the lobular branch of the greater auricular nerve was dissected out. Various measuremenst were taken to the ear, SMAS and mastoid process. Greater auricular nerve diameter was measured. The branching pattern of the nerve and the location of the branches within the Ozturk 30 degree angle were documented.

Lobular Branch Greater Auricular NerveThe lobular branch existed in all specimens and was distributed to three regions. In the vast majority of the time (85%), the lobular branch was located inferior to the antitragus, in the remaining specimens it was located inferior to the tragus. The path of the lobular branch can be determined before surgery by making two vertical lines from the tragus and antitragus down to the McKinney point. The lobular branch ascends within this marked region. These markings provide guidance to avoid injuring the lobular branch during facelift flap dissection and SMAS elevation.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2017

Case Study – Bilateral Cleft Rhinoplasty

 

Background: The bilateral cleft lip and palate deformity poses major reconstructive challenges. At its root cause is the shortage of tissue that has resulted from the cleft as well as scar tissue that has occurred from prior surgeries.

The bilateral cleft nose has many typical features from a wide and blunt nasal tip, an underdeveloped underlying septal support, a columellar shortage of skin and wide flaring nostrils.

A more complete rhinoplasty is done in the bilateral cleft patient during their teenage years when they are past puberty. There is some debate as to whether it should be done before or after an upper jaw advancement which is eventually needed in more than half of bilateral cleft patients. That would depend on when the jaw advancement is planned and how much forward movement is needed. But in most cases it is best done six months or longer after the LeFort I osteotomy has been done.

Case Study: This 17 year-old teenage male had multiple previous surgeries for a bilateral complete cleft lip and palate birth defect. He had completed his upper jaw surgery one year previously. He had a good occlusion and adequate upper lip support. His nose showed a strong and high dorsal line, wide nasal bones and a blunted and ill-defined nasal tip.

Bllateral Cleft Septorhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia he had an open septorhinoplasty performed. The nasal bridge was lowered slightly and the nasal bones narrowed. A septal cartilage graft was used to create a strong columellar strut onto which the tip cartilages could be reshaped. The nostrils were also brought inward.

Bilateral Cleft Septorhinoplasty result oblique view Dr Barry Eppley IndianapolisBilateral Cleft Septorhinoplasty result front view Dr Barry Eppley IndianapoliosHis after surgery results show definite improvement in his overall nasal shape. But like mamy cleft rhinoplasty surgeries the result always leaves one hoping for more.

Highlights:

  1. The bilateral cleft nose poses a reconstructive challenge due to both tissue hypoplasia and tissue scar.
  2. The bilateral cleft rhinoplasty should be done after an upper jaw advancement =has been completed and healed to provide good skeletal support.
  3. The most important reconstructive element in the bilateral cleft nose is to achieve a strong columellar support onto which the nasal tip can be built.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2017

Case Study – Transcoronal Temporal Reduction

 

Background: The width of the head is controlled by the thickness of tissues above the ears. This consists of skin, fat, muscle and bone. Of these four tissue elements, it is surprising for most people to know that the muscle layer is the thickest of all of them. The posterior belly of the temporal muscle is a lot thicker than is usually appreciated often being 7mm to 9mms in thickness.

The temporal or head width reduction procedure that I have developed uses the removal of full thickness muscle to achieve its effect. While most patients and surgeons want to grind down the bone, it is this soft tissue reduction that has the greatest effect. Removing this portion of the temporalis muscle sees like it would create functional problems with lower jaw opening, but it does not. This is because the bulk of the temporalis muscle is located in the anterior belly and there are other muscle (pterygoid and masseter muscles) that play a role in jaw motion as well.

Temporal reduction is usually done through limited incisions that are hidden as much as possible. This is because most patients that have heads that are perceived as being too wide or convex are men who have close cropped hairstyles or shave their heads. Small temporal or postauricular incisions are usually used. In rare cases where a coronal scalp scar already exists or other procedures are being done that necessitate such a long scalp incision will it be done with such open exposure.

Case Study: This young middle-aged male had a prior history of brow bone reduction and an existing full length coronal scalp scar. He was bothered by the width at the sides of his head and its protruding convex shape.

Posterior Temporal Muscle Resection and Parietal Skull reduction intraop bnefore and after Dr Barry Eppley IndianapolisBecause he already had a full coronal scalp incision, a full open approach was done for wide open access to the posteror temporal areas above his ears. The full thickness of the muscle and the overlying fascia were removed.

Temporal Muscle Reduction result front view Dr Barry Eppley IndianapolisHis after surgery results show a reduction in the width of the sides of his head with less convexity. He had no jaw motion restriction or pain even right after the surgery.

Highlights:

  1. A wide side of the head can be reduced by temporal muscle reduction.
  2. The most significant temporal reduction of muscle can be done through an open scalp incision
  3.  Complete temporal muscle removal usually results in significant head width narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2017

Product Review – Juvederm Vollure XC

 

With now over 25 synthetic injectable fillers available in the U.S., one would think there is little need for further filler products. But the ability to modify hyaluronic acid filler structures to create different aesthetic effects assures that more such filler products will continue to become available.

Juvederm Vollure XC Dr Barry Eppley IndianapolisJuvederm Vollure XC has just become FDA-approved for injection into moderate to deep facial wrinkles such as the nasolabial folds. It is formulated with proprietary Vycross technology, which blends different molecular weights of hyaluronic acid, contributing to the filler’s long duration. Juvederm Vollure XC will be available in the United States in April 2017. This specific filler is not new in other parts of the world as it was first approved in Europe under the name of Juvederm Volift in 2013.

In the clinical trial that led to its approval, 59% of patients saw improvement in moderate to severe nasolabial folds for up to 18 months, with 82% of patients saying they were very satisfied at 6 months and 68% at 18 months. With a duration that has been shown to last up to 18 months from the initial or touch-up injection in a majority of patients, this is the longest lasting result shown in a clinical study in the nasolabial folds to date.

Like all injectable fillers it has typical side effects such as swelling, tenderness, bruising, firmness lumps/bumps, redness, pain, discoloration, and itching. Other than lumps of the material these side effects resolved within one week after injection.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2017

Case Study – Forehead Asymmetry Surgery

 

Background: The forehead occupies a full third of the human face and sometimes than that based on the location of the frontal hairline. While the forehead does not draw one’s attention, like the lower two-thirds of the face due to the sphincteric motion of the eyes and mouth, its broad surface can not be overlooked.

Forehead asymmetries are not that uncommon and can result from a variety of causes. One of the most common is that from plagiocephaly where the twisting of the entire skull creates well known front and back of the head asymmetries.  It is also seen in varying degrees of isolated frontal facial asymmetries with the smaller facial side having less forehead projection and a lower brow bone position.

Another less common cause of forehead asymmetry is iatrogenic from prior surgery. In performing brow bone reduction or more superior frontal bone reshaping, slight bony shaoe differences may exist or be created between the two sides. While not apparent during the actual operation, these slight differences may become revealed after surgery as the tissues contract down around the expanse of the broad forehead.

Forehead AsymmetryCase Study: This young middle-aged male had a prior history of brow bone and forehead reduction surgery. While it took months after surgery to see the final shape of his forehead, it eventually showed a forehead/brow bone asymmetry that was confirmed by a 3D CT scan. The left brow bone, in particular, and the upper forehead were flatter than that of the right side.

Intraoperative Custom Forehead Implant 2 Dr Barry Eppley IndianapolisIntraoperative Custom Forehead Implant for Asymmetry Dr Barry Eppley IndianapolisBecause he already had a full coronal scalp incision, a full open approach was done for wide open access to the forehead. Using PMMA bone cement a thinly design implant was fashioned to visually match that of the right side. The edges were burred down to be very thin at their perimeters. It was secured into place with two small microscrews.

Left Foreheasd Augmentation Dr Barry Eppley IndianapolisHis after surgery results show improvement in his forehead shape between the two sides. Careful inspection shows just a hint of the outline of the bone cement application which is surprising given its paper thin edges and the thickness of his scalp tissues. Whether he may eventually undergo a revision for this aesthetic tradeoff remains to be determined.

Highlights:

  1. Forehead asymmetry can be created by brow bone and forehead reduction surgery.
  2. One method of bone augmentation for forehead asymmetry surgery is that of the use of bone cements which requires a wide surgical access for application.
  3. Any method of forehead augmentation requires the smoothest transition between the material and the natural tissues to avoid any visible lines of transition.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2017

Custom Jawline Implant Designs

 

Custom jawline implants provide a powerful tool for lower facial change. Covering the entire jawline from angle to angle provides a lot of surface area coverage to create significant augmentation effects.

These powerful implant changes have a double edge sword effect. With the right implant design and dimensions many desired patient jawline effects can be seen. What the right implant design and dimensions are, however, is never exactly clear before surgery in the designing process. There is no formula or design method that is available that can predict what the implant design to final effect result will be. This remains an artistic process that lacks complete clinical predictability.

Custom Jawline Implant Angle Widths Dr Barry Eppley IndianapolisHaving done many custom jawline implant designs there are three components of the process to consider. They are the chin, the jaw angle area and the connecting body portion. I find that the chin and the connecting body portions are usually straightforward and create few design quandries.

Custom Jawline Implant Angle design and dimensions Dr Barry Eppley IndianapolisCustom Jawline Implant Flare Design Dr Barry Eppley IndianapolisDesigning the jaw angle areas of the implant, however, is a different story. The 3D effects  of its vertical, horizontal and transverse dimensions creates challenging design considerations. Because much of the jaw angle dimensions are off the bone and ‘out into space’ it is hard to precisely predict its effects. How the soft tissue will respond and redrape over expanded hard tissue boundaries is one issue. What aesthetic effect will a larger prominence create at the back of the jaw on both sides is another. The larger the change in the jaw angle area the more unpredictable these effects become.

I have done many custom jawline implants with very satisfying aesthetic outcomes. But I have also seen many other such implants where its effects were unpredicted and had to be revised. In almost every instance it was the jaw angle component that posed the problem. In most instances its appearance not its position on the bone was the issue.

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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