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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.

January 18th, 2018

Case Study – Senior Skull Augmentation with Two-Stage Custom Occipital Implant

 

Background: Flattening of the back of the head is one of the common aesthetic skull deformities. Many of these are mild and are likely caused by how one slept as an infant.  But others are more severe and are caused by a genetic tendency based on ethnicity or familial tendencies or even from lambdoidal synostosis. These more severe flattening of the back of the head are known as brachycephaly and look like the back of the head has been cut off.

While brachycepahaly can be treated by cranial vault remodeling as an infant, the time available to do such bone-based surgery passes quickly. As an older child, teen or adult, such bone-based surgery is not an option. At these ages the concept becomes one of stretching out the overlying scalp by adding to the bone on top of it. While only bone cements have been used in the past to do so, they have numerous limitations and have been replaced by custom made implants based one the patient’s 3D CT scan. Such an approach offer a much better result (smoothness and contour) with a smaller incision length to do so.

A large skull implant augmentation and the amount of increased projection that can be achieved is ultimately determined by the amount of stretch that the scalp will permit. This will vary by a number of factors (scalp thickness, natural elasticity and incisional length access) but, as a general rule, the scalp can safely accommodate a 10 to 12mm immediate increase in central projection. (with a long side taper) Greater amounts of implant projection will require a first stage scalp expansion to accommodate it.

Case Study: This 70 year-old man had been bothered his whole life by the flatness of the back of his head. A 3D CT scan showed  how flat the back of his hand was with a complete lack of convexity. He wanted a significant amount of projection which he estates would be close to an inch.

A custom occipital skull implant was designed from his 3D CT scan based on giving him a  a more pleasing convexity. This measured out to be 22mms of central projection. Because of this amount of increase a first-stage scalp tissue expander was placed. Over a six week period a total expander volume of 200cc was instilled. This correlated with the 200c volume that the custom implant had.

As a second stage procedure the tissue expander was removed and the custom skull implant placed. The amount of scalp expansion was the perfect amount needed for an implant of this size that allowed for a competent scalp incision closure. His immediate after result showed the amount of projection added to the back of his head.

Besides the good improvement obtained in back of the head projection increase is that the patient was willing to do so at 70 years of age. This is a testament to the degree of how much this congenital skull deformity bothered him and the lengths he was willing to go to improve it.

Highlights:

1)  Severe flattening of the back of the head is known as brachycephaly.

2) For significant increased projection of the back of the head a first stage tissue expander is needed.

3) A second state custom skull implant can increase the projection of the back of the head by 25mm or an inch.

4) Age is not a limitation for skull augmentation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

January 15th, 2018

Case Study – The Effects of Breast Implants on Stretch Marks

 

Background: Many women that undergo breast augmentation surgery have had children. As a result of pregnancy and breast engorgement, stretch marks commonly develop. They occur in a radiating fashion from the nipple in a perpendicular orientation to the relaxed skin tension lines of the breast,

Since so many women have breast stretch marks, it is a common question as to how they will appear after the breast is markedly increased in size. There has never been a definitive study of this question although plastic surgeons have an inordinate amount of anecdotal experience with this observation.

Since stretch marks represent incomplete tears of the underlying dermis, it would be reasonable to expect them to get wider as the breast mound inflates with an implant. This is much like the areola as its diameter increases as a result of breast augmentation surgery. But does this stretch mark widening persist and does it look worse on a long-term basis?

Case Study: This young female had two children previously. As a result she lost much of her breast volume and acquired a large number of stretch marks. With a loose and deflated breast mound the stretch marks were not that noticeable.

Under general anesthesia saline breast implants were placed through a transaxillary incisional approach. The implant size was 300cc inflated to 350ccs. Her 6 weeks after surgery rests show that her stretch marks has relax to the point that they looked no worse than before surgery.

Most of the time stretch marks after breast augmentation return to their presurgical appearance. With rare exception stretch marks can appear worse if their color turns red. This is somewhat dependent on implant size and how much stretch is placed on the breast mound.

Highlights:

1)  Many women that undergo breast augmentation surgery have stretch marks.

2)  Like the entire breast mound, stretch marks get bigger with with the push of underlying implants.

3) But with skin relaxation after surgery stretch marks return to their preoperative state.

Dr. Barry Eppley

Indianapolis, Indiana

January 14th, 2018

Custom Occipital Skull Implants

 

The shape of the head is prone to a wide variety of deformational deformities. One of the most common areas for such aesthetic skull deformities to occur is on the back of the head. Lack of projection and asymmetries are the typical occipital problems that bother patients, most of which are men more than women. Having a short haircut or shaved head makes any area of the skull more exposed. Thus it is no surprise that more men undergo aesthetic occipital skull surgery than women.

The best method to treat flatness at the back of the head is with a custom skull implant. This treatment approach offers numerous advantages over the historic use of bone cements for cranioplasty. Being made from the patient’s 3D CT scan, it can create an exacting fit to the underlying bone. It can also correct asymmetries which is very common in any flatness deformity on the back of the head.

One huge advantage with custom occipital skull implants is that the maximum projection can be achieved with their use, within the limits of how much the scalp can stretch. A preformed implant can provide a larger amount of scalp push from underneath as opposed to placing a material and then trying to pull a scalp closure over it. With an incision placed away from the maximum point of projection there is no risk of after surgery wound dehiscence.

But equally relevant is that custom occipital skull implants can be placed through much smaller scalp incisions than can bone cements. Because the implant is preformed the exact footprint and thickness of the implant is preoperatively determined. It silicone composition makes it capable of being rolled onto itself and inserted trough a more limited scalp incision. Once inside the pocket it is unfolded and positioned.

Dr. Barry Eppley

Indianapolis, Indiana

January 13th, 2018

Septal Extension Graft Techniques in Rhinoplasty

 

The projection of the tip of the nose is an important element in rhinoplasty. This becomes of almost primary importance in noses that have inadequate tip projection due to congenital development such as in Asian and African-American noses. Numerous techniques have been used to increase tip projection based on the nasal tripod concept with the central septal support as its foundation. This has led to numerous concepts to create increased tip projections from which the most effective approach is to use it as a support platform to push out the tip from behind it. It is believed that due to the inherent strength of the caudal septum, maintaining as much of its structure as possible is important.

In the January 2018 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft’  In this paper the authors compared two methods of increasing tip projection through extension grafting, a septal extension graft (10mm long grafts) or double-layered ear cartilage interposition grafts, in the amounts of tip projection obtained and its ability to control its rotation. Twenty-seven (27) patients (14 with septal extensions grafts and 13 with ear cartilage grafts) over a two year period were studied. Nasal tip projection and nasolabial angles were measured before, 2 weeks after surgery as well as 7 months after surgery.

Nasal tip projection increased 60% in septal extension grafts and 75% by ear cartilage extension grafting. Longer term followup showed that relapse rates were nearly 40% and 25% respectively. The nasolabial angles increased after surgery by about 3 degrees for both groups which was maintained over time. Over 10% of the total patients required revision surgery for aesthetic reasons. Almost 15% of the total patients developed an infection.

This paper documents that septal extension grafts are effective at increasing and maintaining tip projection. Whether it is harvested from the septum or the ear, both types of extension grafts offered similar structural enhancement, stability and complication rates.

If one wants to maintain complete septal integrity and place a septal extension graft, options also include a rib graft as well as ear cartilage grafts. Ear cartilage grafts in my experience always seem weak and not very stiff. Thus a sliver of rib cartilage is much better. Adding an ear cartilage graft to a PDS plate us another option that could be effective in this rhinoplasty technique.

Dr. Barry Eppley

Indianapolis, Indiana

January 13th, 2018

Open Structural Technique in the Asian Cleft Rhinoplasty

 

Rhinoplasty can be a difficult operation in many noses. But its difficulty rises when rhinoplasty is needed in the cleft patient due to the structural deficiencies and asymmetry of the nasal cartilages and the often scarred and thick tissues from prior nasal surgeries. It becomes even more challenging in the Asian cleft patient who has a genetic tendency of a  flat, short and under projected nose. This then become a challenge of not only making the cleft side of the nose look better but to enhance the non cleft side of the nose as well.

In the December 2017 issue of the Aesthetic Surgery Journal an article was published entitled ‘Asian Cleft Rhinoplasty: The Open Structural Approach.’  In this paper the authors present their experience using an open structural technique for Asian cleft rhinoplasty using rib cartilage and temporalis fascia. The basic tenets of their approach include a central septocolumellar graft combined with extender spreader grafts (from rib) to lengthen the tip of the nose. The dislocated lower alar cartilage on the cleft side was then completely detached and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was reconstructed with the lateral crural strut graft. Tip suturing and cartilage grafting was done. Dorsal augmentation was accomplished using diced cartilage wrapped in temporal fascia. At closure, a reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base reductions were done as needed and the depressed alar base augmented with a small rib graft.

Over a five year period, thirty-fee (35) Asian parents underwent open cleft rhinoplasty.  (18 females, 17 males and 23 unilateral clefts and six bilateral clefts) There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral clefts and 6 were bilateral clefts. All patients were highly satisfied with the functional and aesthetic improvements of their nose. The complications ( infection) and revision rates (2 patients) were low.

This paper documents the use of the open rhinoplasty approach using all autologous materials. (rib and temporal fascia) It avoids the use of any synthetic materials which are commonly used in many aesthetic Asian rhinoplasties. The key to the technique is the septocolumella graft in the midline which saves as the central tentpole of support onto which tip projection and nasal length can then be set.

Dr. Barry Eppley

Indianapolis, Indiana

January 11th, 2018

Case Study – Subcostal Rib Contouring for Protrusion Removal

 

Background: The ribs occupy a large amount of one’s torso, encompassing substantial surface area coverage on the chest and back. With twelve pairs of ribs (sometimes one less or more) , these 24 body parts provide structural support  and protection for the any organs that keep us alive. While seemingly simple in their design , their location and composition (bone vs cartilage) make for a variety of potential ribcage deformities.

One of the most common areas for such aesthetic deformities is the subcostal rib region. This lower chest area is composed of the merging of the mainly cartilaginous ribs #7, 8 and 9 from the side of the chest into the sternum. When deformities in this area occur, they are especially noticeable but also can cause discomfort in this very palpable area.

The subcostal rib region is prone to deformities particularly from injury. It’s lower margin often sticks out and becomes a prominent target for traumatic events. Because these rib portions are cartilaginous and, more importantly, have an osseo-cartilaginous junction brunt trauma can cause shape deformities. Partial separation of the osseo-cartilaginous junction, subperichondrial hematoma and partial rib cartilage fractures can all make for a prominent subcostal rib protrusion.

Case Study: This middle-aged male developed a very prominent bump along the right subcostal rib margin. It was not present at birth or through the earlier years of his life.  It developed without specific recollection of any traumatic event. While he had overall prominent subcostal rib margins due to his very the body frame, there was a very distinct prominent bump on the right subcostal margin along rib #8. It was medial to the osseo-cartilaginous junction.

Under general anesthesia a small 3 cm incision was made directly over the rib bump. The rectus muscle was vertically separated and the prominent cartilage bump exposed. It was shaved down with a scalpel as much as possible within the limits of what the incision would permit. Then a rotary handpick and burr was used to take it down further and feather into the surrounding rib edges. (rib contouring)

Prominent subcostal rib bumps or protrusions can be very successfully reduced through a small direct incisional approach. While this patient’s case represents the smallest example of subcostal rib contouring, the technique is effective nonetheless.

Highlights:

1) One reason for rib contouring surgery is for prominent and painful rib protrusions.

2) The anterior subcostal ribs margin is a common place for cartilaginous protrusions.

3) Depending on the size of the protrusion, rib shaving reduction is a good technique for its treatment.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2018

Case Study – Rhinoplasty for the Long Thin Nose

 

Background: Rhinoplasty changes the shape of a wide variety of noses. This is why a large number of nasal reshaping techniques exist and the ‘cookie cutter’ approach to rhinoplasty surgery will leave some patients wanting. Besides identifying what anatomic structures create the nasal shape seen, it is also important to recognize what effects modifying the structural support of a nose will do. Failure to do ends up with indentations  and asymmetries long term as scar tissue contraction distorts a weakened cartilage structure.

One such nose that poses a challenge is the long skinny nose. It has excessive cartilage length but at the same time the lower alar cartilages are thinner and structurally weak. The nasal skin is almost always very thin revealing any irregularities underneath it. Shortening the tip of such a nose is fraught with the potential for lower alar collapse and notching.

Case Study: This petite young female presented for rhinoplasty with the following aesthetic deformities; a small nasal hump, an overprotected nasal tip, an irregular dorsal line, nasal asymmetry, left middle vault collapse, alar rim retraction and widely flaring nostrils. She had no breathing difficulties.

Under general anesthesia an open rhinoplasty approach was used to perform the following maneuvers. A eptoplasty to straighten it as well as harvest grafts, angled resection of caudal septum, hump reduction by cartilage shave and bony rasping (no osteotomies), bilateral spreader grafts, tip shortening by medial footplate resection, medial cephalic trim of lower alar cartilages,  tip suturing, columellar strut grafts, alar rim grafts and alar flaring reduction.

In many rhinoplasties the concept of what is added is just as important as what is removed. While not true for all aesthetic nasal surgery, many patients need a redistribution of cartilage structure rather than a removal of cartilage alone.

Highlights:

1) The long thin nose is a challenge in rhinoplasty that requires both reduction as well as adding structural support.

2) Deprojecting the kong thin tip must be done carefully to avoid over rotation and weakening of the low alar crura.

3) Spreader grafts can help widen the middle vault in a thin nose as well as improve asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2018

Case Study – Custom Jawline Implant Replacement for Malpositioned Chin and Jaw Angle Implants

 

Background: Jawline augmentation today usually refers to enhancement of its three primary aesthetic points, the chin and two jaw angles. There are a variety of standard preformed chin and jaw angle implants to achieve this effect and, with proper implant style and size, satisfactory results can be achieved.

But beyond the challenge of selecting the right implant style and size for three different bony jaw areas, there is the need to place them in the proper bony location to exert their desired external effects. The latter is often taken for granted by the patient but not by the surgeon. Placing three implants at different locations on the jawline without being able to reference one to the other due to the limitations of incisional access makes this part of the operation more difficult than it seems. This is far more challenging than placing a single chin implant or even paired cheek implants.

As a result the incidence of implant malposition and asymmetry is not all that uncommon in a three implant approach to jawline augmentation. This risk is magnified when the patient has pre-existing jaw angle bony asymmtetry which may or may not have been recognized before surgery.

Case Study: This middle-aged male had total jaw augmentation previously with a standard anatomic chin and widening jaw angle implants. While the patient recognized that his jaw was asymmetric after the surgery, his surgeon assured him the implants were in good position. A 3 D CT scan showed that the chin implant was positioned too high and to the left and the jaw angle implants were in completely different positions, neither of which was in ideal position.

Using this 3D CT scan a one-piece jawline implant was designed to correct his asymmetries. The dimensions of his existing implants (projections) served as a good guideline as to the size of the various ‘corners’ of the jawline implant.

Under general anesthesia and using an external submental skin incision combined with bilateral posterior vestibular incisions, his chin and jaw angle implants were removed. The new one-piece jawline implant was able to be inserted as the intact piece by which it was designed. His results with pictures taken years later showed good jawline/lower facial asymmetry and better chin and jaw angle projections.

There are many patients in whom standard chin and jaw angle implants work well. But it is not easy to successfully place three independent jaw implants in a perfectly symmetric fashion. Even with a lot of surgical experience it can still happen. When a three-piece jaw implant approach has not been successful, a custom jawline implant will offer improved results by its ‘one implant’ design.

Highlights:

1) Total jawline augmentation done with standard implants has a relaltively high risk of malposition/asymmetry of at least one of the implants since there are three implants used.

2)  A 3D CT scan can confirm standard jawline implant positions as well as be used for a one-piece total jawline implant.

3) Indwelling implants provide dimensional guidelines in designing a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2018

Technical Strategies – Two-Piece Custom Skull Implant for Large Augmentations

 

Aesthetic augmentation of the skull is most effectively done using 3D imaging technology to create a custom skull implant. By both creating an exacting fit and the desired amount and shape of the skull augmentation beforehand, surgery becomes focused exclusively on the method of placement. The consideration of the location and length of the scalp incision, ensuring adequate pocket dissection can be achieved and enabling the implant to be inserted and properly positioned becomes the surgical goals.

3D designing enables skull implants to be created that are capable of augmenting almost all of the skull. The limitations of the size of skull implants is controlled by two factors, the amount of scalp stretch to contain them and how successfully they can be manufactured. The judgment of how much the scalp will stretch to have a competent incisional closure is important and almost all very large skull implants need a first stage scalp expansion.

Successfully manufacturing of large silicone skull implants means that it can not exceed a surface area coverage below the equator of the skull. (basically a line around the skull at the brow bone level) When the lower implant edges turns in (at the equator or below) the implant integrity can not be assured.

To avoid a complete coronal scalp incision (which I try really hard to avoid in aesthetic skull surgery for just about any purpose), a one-piece implant can be difficult if not impossible to pass through the incisional access. (less than a coronal incision) In these cases a two-piece approach is used in the manufacture of the implant. By inserting the two pieces independent of each allows the integrity of the scalp incision to be maintained and not need to be lengthened.

Once both custom skull implant pieces are placed into the patient, they are then assembled and sutured together to create a tight interlocking fit. Between the fit of the implant and the suture union of the two implant half, there is no benefit for any further fixation given the compression of the scalp over the implant.

Dr. Barry Eppley

Indianapolis, Indiana

January 6th, 2018

Case Study – Choosing Earlobe Reduction Techniques

 

Background: Earlobes elongate over time because they have no structural support. They are the only part of the ear that does not contain cartilage. As a result the effects of gravity do make true the old adage that the ‘ears do grow longer as we age’. (although stretching of soft tissue, a passive process, should not be confused with an active growth process that makes new tissue) Certain external factors can exaggerate this natural elongation of the earlobes such as heavy ear ring wear and even facelift surgery if not well done.

Large or long earlobes are unattractive because they are disproportionate to the size of the rest of the ear but can also be viewed as a sign of aging. Earlobes can be very effectively reduced by a variety of tissue excision techniques.While many types of earlobe reductions have been described, they fundamentally come down to a wedge excision through the body of the earlobe or an elliptical excision oriented across the bottom of the earlobe. Each approach has its own advantages and disadvantages.

Case Study: This young female was bothered by the large size of her earlobes. Even though she was fairly young, she had an earlobe length that was  1/3 or greater of her vertical ear height. (as measured from the intertragal notch superiorly down to the bottom of the earlobe or subaurale)  She had two earlobe holes from piercings. The lower one she wanted removed as it had a chronic infection. The second or upper one she wanted to keep and have it moved more anteriorly to replace the removed lower one. Her earlobes had an unattached facial connection.

In considering the removal of the lower half of the earlobe, the inferior helical rim excision technique, the first ear piercing may or may not be completely removed. But a small vertical excision can be done to ensure that it is at the same time. The second ear piercing, however, will remain and will do so in the same position that it currently sits. This technique maximally reduces the earlobe as well as can maintain an unattached earlobe connection. (inverted V)

The wedge excision technique, with the anterior limb placed at the facial junction, will both remove the anterior piercing as well as move the second piercing hole much further forward. How much it moves will depend on the size of the wedge and the location of the posterior limb of the excision. It does not shorten the earlobe as much as the inferior helical rim technique and creates an attached earlobe connection. (regardless of what it was before)

The aesthetic advantage and disadvantages of each earlobe technique must be considered. In this case the patient opted for the wedge excision as it was important to have the posterior piercing hole moved forward. Even though the tradeoff to do was less of a vertical reduction and the change to an attached earlobe connection.

Highlights:

1) Earlobe reductions are done by a different excisonal tissue patterns.

2)  The location of piercing holes and whether the earlobe is attached or unattached will influence the type of earlobe reduction done.

3)  Wedge excision earlobe reductions  maintain or create an attached earlobe to the face.

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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