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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.

September 1st, 2016

Case Study – Rhinoplasty for the Pinocchio Nose

 

Background: The long protruding nose is well known in rhinoplasty and has been referred to as the ‘Pinocchio Nasal Deformity’. Such a description has been cited in plastic surgery articles all the way back to 1974. More anatomically described as an over projecting nose, it is the result of an elongated cartilaginous framework from the septum and lower alar cartilages. These three cartilage structures merge at the nasal tip making the lower third of the nose look way out of proportion to the nose and face behind it.

The correction of the Pinocchio nose was originally described by a radical tripartite cartilage excision of the nasal tip and the subsequent reduction of the nose above it to fit the new tip position. In essence this means that the the tripod cartilage unit at the end of the nose is resected and set back. This may or may not involve some degree of tip rotation. Once the nasal tip is set back it often becomes evident that there is a nasal hump above the new lowered dorsal line that also needs to be addressed.

While cartilage and bone can be reduced and reshaped, the same can not be said for the skin. What happens to the now excessive skin depends on its natural ability to shrink back down to a smaller underlying supportive cartilage framework. Fortunately in many case of the over projecting nose the skin is thinner and does this fairly well. But thicker nasal skin patients may not have the same soft tissue response.

Case Study: This 43 year-old female presented for rhinoplasty surgery. She had a very long and thin nose that also had significant tip asymmetry due to buckling of the tip cartilages.

Pinocchio Nose Rhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia and using an open rhinoplasty approach, the caudal end of the septum was resected and the lower alar cartilages shortened by a dome division/resection technique. The septum was straightened and cartilage grafts harvested. The now apparent nasal hump was reduced and middle vault spreader grafts placed.

Pinocchio Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisPinicchio Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisAt one year after surgery the dramatic improvement in the appearance of her nose could be appreciated. It is not an ideal result as there remains some residual fullness and asymmetry on the left side of the nasal tip.

The over projecting nose illustrates what happens when the cartilage structure of the nose becomes overgrown. Driven by the midline septum, the growth center of the nose, its elongated development drives the upper and lower alar cartilages with it. This creates the Pinocchio nose

Highlights:

1) The pinocchio nose deformity is the result of an elongated septum and long lower alar cartilages.

2) Shortening the long nose requires cartilage reduction and tip reshaping manuevers to pull the nose back toward the face.

3) How much shortening the nasal tip that can be obtained partially depends on how well the overlying skin shrinks down to the shortened cartilage framework.

Dr. Barry Eppley

Indianapolis, Indiana

August 30th, 2016

Vanquish ME for Non-Surgical Fat Reduction

 

The market leader for nonsurgical fat reduction is Cryolipolysis or Cool Sculpting. It is the market leader not necessarily because it is the best body contouring device but because it is certainly the most heavily marketed to both physicians and patients. But it is not suitable for every patient that seeks nonsurgical fat reduction because of the limitation  of applying the paddles which deliver the cooling energy to create its effect. Thus it is usually limited to patients that have a BMI less than 25.

Vanquish Body Contouring Dr Barry Eppley IndianapolisVanquish ME is a better device for larger patients like those with BMIs over 30. Because of the large spot size and non-contact external applicators, it can treat many patients that are not suited for Cool Sculpting and other modalities. A recent study found that a series of four Vanquish treatments without manual massage resulted in an average reduction of the abdominal fat thickness of over 5mms as assessed by MRIs.

Given that 30% of the population has a BMI that is over 30, spot treatments offered by many devices would be completely ineffective. This leaves a large number of people not seeking to undergo liposuction has candidates for Vanquish treatments. Vanquish results usually become evident in just a month after beginning treatments so patients usually stay motivated to complete the treatments and often go on to a second series.

When Vanquish is combined with Exilis Ultra to increase tissue heating the amount of skin contraction and tissue tightening is enhanced. The new Cellutone also speeds he onset of results. Adding a massage component to body contouring techniques is well known to be beneficial. When added to a non-invasive fat reduction treatment series it has been shown to nearly double the amount of abdominal reduction seen.

Dr. Barry Eppley

Indianapolis, Indiana

August 30th, 2016

Case Study – Calf and Ankle Liposuction

 

Background: Liposuction is the most well known fat removal method and has been around now for over forty years. As the surgical techniques and equipment have evolved over this time, fat has been extracted from every conceivable location on the human body. Depending upon the body location and the amount of fat removed liposuction can serve as a volume reduction method or more of a sculpting method.

One of the most challenging areas on the whole body is that of the lower legs. Thick lower legs that have an indistinct shape defy exercise or any other therapy to improve their look. Liposuction is the only method to do so and relies on the premise that too much fat is why they look the way they do.

While excess fat is most certainly a major contributor to the thick lower leg, it is not the only tissue present. The large size of the calf muscles and even the bones are part of he make up of the leg. These tissues are not modifiable and ultimately serve as the limiting factor into how much the size and shape of the lower leg can be improved.

Case Study: This 34 year-old female desired lower leg reshaping. She had thick legs her whole life and would not wear shorts or skirts because of them. They were a lifelong source of embarrassment. While she did not have a thin body habitus she was not significantly overweight either.

Under general anesthesia small cannula liposuction was performed on the inner knees, the entire calfs and on both sides of the ankles. A total of 1,275cc of fat aspirate was obtained between both lower legs.

Calf and Ankle Liposuction results front view Dr Barry Eppley IndianapolisCalf and Ankle Liposuction result back view Dr Barry Eppley IndianapolisHer results show some modest improvement in the shape of her lower legs. They had a more evident knee and calf definition and were somewhat smaller. It took almost three months until all the swelling had completely gone way.

Reshaping of the lower leg by liposuction produces modest improvement. It is usually never dramatic and can not a big leg and make it a small leg. Its improvement comes by making the underlying shape of the muscle more evident.

Highlights:

1) Reshaping of the larger leg can only be done by liposuction from the knees down to the ankles.

2) The effects of liposuction on the lower leg are limited by the amount and location of the fat that can be removed from the subcutaneous layer.

3) Swelling from lower leg liposuction will take up to three months to completely resolve.

Dr. Barry Eppley

Indianapolis, Indiana

August 30th, 2016

Case Study – The Perfect Breast Augmentation

 

Background: With almost a million breast implants placed per year in the U.S. for aesthetic breast augmentation, the results achieved are highly variable even though the implants have the same basic shape. This is due a basic breast augmentation concept….all breast implants do is take what you have and make it look bigger.

Breast implants do not have the capability to fix natural breast asymmetries, sagging breasts, where the breast mound sits on the chest wall or change the position/shape of the nipple-areolar complex. Implants are simple mound enlargers that have no other magical properties to do more. For this reason it is critical that the patient be aware of what breast implants will or will not do before surgery so their postoperative expectations are realistic.

While most women will achieve satisfying results from their breast implant surgery, few women ever achieve a perfect result by either patient or surgeon assessment. This is for the simple reason that few breasts are ever perfect initially and that the placement of paired synthetic implants into the body can create different responses in healing.

Case Study: This 20 year-old female presented for breast augmentation desiring a full round breast look result. She opted for high profile silicone implants.

Perfect Breast Augmentation results front view Dr Barry Eppley IndianapolisUnder general anesthesia she had 350cc high profile silicone implants placed trough 3.5 cm long inframammary incisions in the partial submuscular dual plane position. (it required her nipple piercings to be removed right before surgery)

Perfect Breast Augmentation results oblique view Dr Barry Eppley IndianapolisPerfect Breast Augmentation result side view Dr Barry Eppley IndianapolisHer breast augmentation result is as good one as one can get. This is judged by the symmetry of the breasts and their rounded shape which she desired. While good placement and surgical technique was needed, it was aided by the good symmetric shape of her breasts before surgery.

Highlights:

1) The best breast augmentation results occur in those women who have the best breast tissue/shape before surgery.

2) A high profile silicone breast implant produces a fuller looking breast mound with good upper pole fullness.

3) Symmetry is an important element of a good breast augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

August 27th, 2016

Case Study – Custom Jawline Implant in a Thin Face

 

Background: A well defined and angular jawline has become a desired facial feature for many young men. (and some young women as well) While the strength of the male jawline has never gone out of style, the influence of the internet, social media and smart phones has made it more desirous than ever.

Improving a weak jawline has traditionally focused on chin augmentation. But in today’s contemporary plastic surgery jawline enhancement has evolved to be much more. The evolving styles of jaw angle implants ha enabled the back of the jaw to be augmented to go alone with chin augmentation. Total jawline augmentation is now possible with the use of combined chin and jaw angles implants. Their numerous styles and sizes allow a wide range of jaw enhancement effect.

But the use of preformed implants in a three-piece approach has its limitations. Because the implants are not connected a smooth transition from one implant to the other may not occur. This also limits any significant vertical lengthening effect of the complete jawline. Any jaw asymmetries will be also unlikely to be improved.

The fabrication of a custom jawline implant from a 3D CT scan has a valuable role to play in achieving a lower facial effect that even the best preformed chin and jaw angle implants can not. Because it is custom designed and made it is the best implant approach to have a smooth jawline effect with distinct angularity to it.

Custom Jawloine Implant design Indianapolis Dr Barry EppleyCase Study: This 25 year-old male wanted to improve the shape and definition of his jawline. He wanted  some overall augmentation but more pertinently wanted a well defined and smooth jawline shape. A 3D CT scan was used to make a one-piece jawline implant that provided vertical length along the lower jawline as well as greater squareness to the chin and the jaw angles.

Under general anesthesia the jawline implant was placed through a combined external submental incision and bilateral intraoral incisions. It was able to be inserted as a single piece implant. (although not all custom jawline implants can be) It was secured with three point screw fixation.

Custom Jawline Implant result oblique view Indianapolis Dr Barry EppleyCustom Jawline Implant result Indianapolis Dr Barry EppleyCustom Jawline Implant result side view Indianapolis Dr Barry EppleyHis one year long-term result shows a much more distinct jawline shape with smooth connections from angle to angle. It is important to recognize that not all men, even younger men, can end with such a new jawline shape. One has to have thin facial tissues to show the full effects of the implant. This is evident in almost any face that has a distinct jawline….limited fat and loose skin to allow the shape and size of the lower jawbone to be seen.

Highlights:

1) Creating a well defined and crisp looking jawline requires a thinner face with little subcutaneous fat to see the outlines of the implant.

2) Only a custom jawline implant that wraps around the edge of the bone can create a smooth lower facial contour.

3) The dimensions of the implant are influenced by how much chin projection and the vertical and width increase of the jaw angles.

Dr. Barry Eppley

Indianapolis, Indiana

August 27th, 2016

The Upper Nasal Lift

 

Reshaping of the nasal tip is an important element of many rhinoplasty surgeries. Elevation of the nasal tip, known as increasing tip rotation, opens up the nasolabial angle and is commonly done in many female rhinoplasties. Having a nasolabial angle greater than 90 degrees (usually 95 to 105 degrees) is desired for the female nose. There are many technical maneuvers done to create this nasal tip change (cephalic trim, caudal septal resection, tip-septal suturing to name the most common) and they all can be very effective.

In rare cases direct ‘tip lifting’ techniques may not work well. This can occur in the nose that has had numerous surgeries and has developed thick scar tissue and lacks good skin retraction capabilities. Thicker scarred skin is harder to lift unless it is driven upward by a cartilage framework that is expanded to provide the underlying push. But building out the  tip cartilages can make the nose too long and is not appropriate for all cases.

The older nose is also known to develop tip ptosis or sagging due to loss of ligamentous support from the tip cartilages. Thus it is true that the nose does elongate with age. Many older patients may not want to undergo a formal tip rhinoplasty for a tip rejuvenation benefit.

Nasal Lift intraop Dr Barry Eppley IndianapolisNasal Lift intraop side view Dr Barry Eppley IndianapolisOne method for refractory or older nasal tip sagging is an upper nasal lift. This is where a segment of skin is removed across the bridge of the nose where the frontonasal frown line is located. A horizontal elliptical skin excision of 5mms or more can be done. Like any distant skin pull on the face, it does not translate into a 5mm upward pull on the nasal tip however. The distant effect is less, usually only about 25% to 50%, down 3 to 4 cms from the excision site. When combined with other traditional direct tip lifting techniques its effect can be enhanced.

Because it is a skin excision, it will result in a fine line scar across the upper bridge of the nose. While this type of nasal incision can heal very well, it is best reserved for older patients who have developed some skin laxity. In older patients I have observed that the scar becomes imperceptible with time and scar maturation.

Dr. Barry Eppley

Indianapolis, Indiana

August 27th, 2016

Double Duck Lip Lift

As the face ages many changes occur around the mouth which are well known. Such structural changes include lengthening of the upper lip, loss of vermilion height and tissue thinning and a decrease of the nasolabial angle in some people. (due to dropping of the nasal tip) The combination of tissue lengthening and volume loss with some resorption of the underlying bony pyriform aperture is the culprit.

Many contemporary treatment strategies exist from injectable fillers, neuromuscular modulators to surgical lip lifts. The subnasal lip lift is often viewed as a last resort treatment approach but for some patients it should clearly be the first. There is no more effective method for shortening the long upper lip than the excision of skin. The subnasal technique in lip lifting is often chosen because of its more hidden scar even though its effects is limited to the central part of the upper lip.

In an effort to manage the change in the nasolabial angle during a lip lift, the technique of moving part of the de-epithelized skin into the base of the columella has been previously described. This creates an opening in the nasolabial angle as well as increases columellar length.

In the 2011 Brazilian Plastic Surgery Journal (volume 26), a paper was published entitled ‘Double Duck Nasolabial Lifting’. In this paper the authors describe a procedure designed to both shorten/lift the upper lip as well as change the nasolabial angle. The technique includes a transverse incision of nasal floor and alar margin skin, separation of the upper lip skin from the underlying orbicularis muscle down to the vermilion-cutaneous junction, the placement of a permanent transcolumellar suture between the nostrils, resection of upper lip skin using a trapezoid resection at the nasal floor and an elliptical pattern at the alar margins and final skin closure.

The authors report satisfactory results in 90% of the patients characterized by shortening of the upper lip, increased vermilion exposure (centrally) and opening of the nasolabial angle. They conclude that the “double duck” lip lift technique was effective with good concealment of the scars.

The term double duck lip lift comes from the pattern of the incisions used in the technique. While the pattern of the incisions is not necessarily novel, what is done with the mobilized skin is. Rather than resecting skin across the base of the columella as in the traditional subnasal lip lift, the skin is spared and moved up into the the base of the columella. (after columellar skin mobilization) This is what also creates the central lip shortening as well as the increase in nasal tip projection.

The double duck lip lift isn’t for every patient that wants/needs a subnasal form of lip lifting. But for the properly selected patient it can be an effective technique.

Dr. Barry Eppley

Indianapolis, Indiana

August 25th, 2016

Case Study – Jaw Angle Implants after Mandibular Osteotomy

 

sagittal split manidbular osteotomyBackground: The sagittal split mandibular osteotomy (SSRO), most commonly used for lower jaw advancement, is one of the most ingenious of all the craniomaxillofacial osteotomies. Splitting the ramus of the mandible longutudinally into two vascularized bone segments is a technical marvel. It allows the distal tooth-bearing portion of the lower jaw to be moved forward while leaving the proximal TMJ-containing bone segment in place. This maintains good bone contact that is fixed together and heals without creating a bone defect.

While the bones segments of a sagittal split mandibular osteotomy do maintain the shape of the jaw angle during the procedure, the jaw angle shape can adversely change as it heals. Some bony resorption of the jaw angle is not rare as the proximal bone segment not only becomes thinner afterwards but probably suffers some degree of devascularization in some cases. This resorption pattern can make the back of the jaw look thinner with a higher jaw angle shape externally.

Such jaw angle shape deformities after a mandibular osteotomy is more prone in thin jaws, inadvertent fracture patterns (aka ‘bad splits’) and repeat sagittal split procedures. The best diagnosis of the jaw angle shape is a from a 3D CT scan where the two sides can be compared in both frontal and side views.

Case Study: This 22 year-old female had a history of orthognathic surgery consisting of a LeFort I, mandibular sagittal split osteotomies and a sliding geniplasty several years previously. She felt that her lower face was too thin and lacked any definition as well has still had inadequate chin projection.

Vertical Lengthening Jaw Angle Implants after Sagittal Split intraop Dr Barry Eppley IndianapolisUnder general anesthesia she had a total jawline augmentation done using standard implants. An anatomic extended chin implant of 8mms projectionwas placed through an intraoral incision. Then using new preformed vertical lengthening jaw angle implants (7mms lengthening and 5mms width), they were inserted intraorally through her previous incisions. The jaw angle implants were placed below the existing bone plates used to secure the mandibular osteotomies and posed no problems for their placement. The jaw angle implants were screwed into placed with a percutaneous screw fixation technique.

Simulated Vertical Jaw Angle Implant effects oblique view Dr Barry Eppley IndianapolisSimulated Vertical Jaw Angle Implant effect Dr Barry Eppley IndianapolisThe goal of the jawline enhancement was to create a more visible jawline both at the front and back of the jaw. By bringing the chin further forward and rotating the jaw angles downward a more distinct lower jaw shape is created as seen in this preoperative predictive imaging.

Highlights:

1) Loss of the jaw angle shape can occur after sagittal split osteotomies due to bone resorption.

2) Jaw angle implants can either restore or augment the shape of the jaw angle.

3) Whether the jaw angle implants should be standard or custom made depends on how much bone resorption has occurred and the amount of bony asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

August 24th, 2016

Technical Strategies – T-Shaped Chin Reduction Osteotomy

 

The traditional chin bone procedure for aesthetic enhancement is that of a sliding genioplasty. Cutting the chin bone and moving it forward has been a facial bone reshaping procedure that has been done for over half a century. It is mainly used as a bony alternative to a synthetic chin implant for chin augmentation. It is less frequently done for reductive chin procedures not only because there is less need but there is generalized less public and even surgeon awareness.

Reducing the bony chin works best for reducing its height and/or width. Moving the bone back for horizontal chin reduction is fraught with causing other soft tissue problems. Such bony chin manipulations have achieved greater awareness more recently due to the popularity of the so called ‘V-line’ Jaw surgery. While frequently used in Asians to reduce their wide and prominent jawlines, it is becoming more common to use it in females with a large lower jaw of any ethnicity.

T-Shaped Chin Reduction intraop 1 Dr Barry Eppley IndianapolisT-Shaped Chin Reduction intraop 2 Dr Barry Eppley IndianapolisA fundamental component of V-line jaw surgery is in how the front part of the jaw, the chin, is reduced. To shorten and narrow it the type of osteotomy pattern (bone cuts) must be different than the traditional sliding genioplasty. While a horizontal bone cut is still used, a double horizontal bone is used to reduce the vertical chin height. The space between the bone cut depends on how much vertical height needs to be shortened. The down fractured chin segment is then cut vertically in two parallel cuts whose space between them is the amount of chin width that has been predetermined to be reduced.

T-Shaped Chin reduction intraop 3 Dr Barry Eppley IndianapolisThis leaves the chin in three pieces; a stable fixed upper segment and two smaller mobile lower segments. The three bone segments are brought together with midline alignment of the two lower segments and fixed together by a single plate and screws. The bone cut patterns and how the chin is put back together creates the T-shape.

Since the chin width is narrowed by sliding the bone segments to the middle, there is often a step off along the lower edge of the jawline at the back end of the horizontal osteotomy line. Care must be taken to look for it and reduce it if needed.

Chin Reduction Reshaping Osteotomies result front view Dr Barry Eppley IndianapolisChin Narrowing Osteotomies result Dr Barry Eppley IndianapolisThe success of this type of chin reduction depends on how much bone is removed and how well the overlying soft tissue adapts to a smaller underlying bone support.

Dr. Barry Eppley

Indianapolis, Indiana

August 21st, 2016

Technical Strategies – Frontal Bossing Reduction

 

Frontal bossing is a not uncommon forehead condition marked by variable amounts of upper frontal bone protrusion. This can appear as smaller bilateral concentric horns or as an overall larger convexity of the whole forehead. Such frontal bone development throws the whole forehead out of aesthetic balance for either male or female and becomes an inadvertent facial focus. For those so affected camouflage is a frequent management strategy with hairstyles or hats.

In infants and very young children forehead reconstruction can be done by removal and replacement of the reshaped bone. But in adults such an aggressive approach is neither possible or warranted as it is an aesthetic concern. Burring reduction of the prominent portions of the forehead is the contouring procedure used. (frontal bossing reduction)

Frontal Bossing reduction inatrop result top view Dr Barry Eppley IndianapolisFrontal Bossing Reduction intraop result right oblique Ddr Barry Eppley IndianapolisHow successful burring reduction is for frontal bossing depends on the thickness of the frontal bone and the amount of bony protrusion. The best way to determine how much forehead bone can be reduced is by getting a 3D CT scan. Cross-sections of the forehead will beautifully show the thickness of the bone and the three skull layers. Seeing the layers is critical as it is the thickness of the outer cortical layer that matters since this is the location of the skull bone that can be reduced. Burring reduction does not usually go into the central diploic space due to the amount of bleeding that is encountered.

Burring reduction is usually very effective as few people need more than 4 to 6mms of bone reduction to substantially lessen or eliminate their bossing.

Frontal Bossing Reduction technique Dr Barry Eppley IndianapolisBeyond how much bone can be removed is the issue o the incisional location to do it. In most cases either a hairline (pretrichial) or hemi-coronal incision is placed several centimeters behind the frontal hairline. The key is that the incision must allow for a direct line of sight to the bossing to be able to get the rotary instrument in to reduce it. This picture one side reduced compared to the bossing side through a scalp incision.

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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