EXPLORE
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 15th, 2017

OR Snapshots – Custom Forehead Implant

 

The aesthetic correction of a retroclined or sloped forehead can be done by a variety of surgical techniques. Fat has become popular as an ‘easy’ injectable method of augmentation but it is important to remember that it is best used for soft tissue augmentation. In most cases forehead augmentation is a bony deficiency not a soft tissue one. Fat injections into the forehead can be unpredictable in terms of volume retention and smoothness so it is not a primary forehead augmentation procedure.

A variety of implant materials can be used in the forehead. Bone cements have a long history as a skull augmentation material including in the forehead. While effective their use requires a near coronal scalp incision for placement and is prone to irregularities and edge deformities. Their shape also depends on the surgeon’s artistic skills and being able to translate the patient’s aesthetic desires into a moldable shape.

Custom Forehead Implant Dr Barry Eppley IndianapolisAll of the potential negative aspects of bone cements for forehead augmentation are eliminated by the use of a 3D custom forehead implant. The exact shape and edging of the implant are determined and made before surgery. The insertion of the implant is done through a much smaller scalp incision due to its flexible nature. Tissue ingrowth into the implant is fostered by the placement of numerous perfusion holes. The outer smoothness of the augmented shape is assured by its preoperative design.

A custom forehead implant offers a superior method of aesthetic forehead contouring in my experience. While it still requires accurate placement of its predetermined design, the number of variables that can lead to undesired effects is reduced by its basic concept.

Dr. Barry Eppley

Indianapolis, Indiana

January 15th, 2017

Case Study – Combination Breast Implant and Lift Surgery

 

Background:  The breast is subject to many changes from the influences of time, gravity, pregnancy and fluctuation in weight. But whatever the cause the changes are very typical, loss of breast volume and sagging. Efforts to reverse these negative shape changes are also very consistent through the addition of volume and lifting and tightening the breast skin.

Breast implants can have a lifting effect but it is not as significant as many patients hope. The lifting effect of an implant works best when the breast sag is no greater than the nipple being ideally above the lower breast fold or even just at the fold level. Because one of the effects of implant expansion on the breasts is to fill out the lower pole and even lower the level of the fold to accommodate the additional volume, the nipple and the breast mound will seem to be lifted. This change is partly illusionary but there is some real lift involved also.

Significant breast sagging, however, requires some type of breast lift even when implants are used. The two types of breast lifts that have real lifting power are the vertical (lollipop) and combined vertical-horizontal (anchor style) techniques. Combining implants and lift in a single breast reshaping operation is challenging as the two operations work against each other, one expanding the breast volume and the other lifting and tightening the breast mound. Getting the right balance between the two that can meet the patient’s expectations often requires more than one operation.

Case Study: This 32year-old female wanted to reshape her deflated and sagging breasts after having several children and losing weight. She had loose stretched out breast skin as well as asymmetry with the left breast sagging lower than the right.

Breast Implant and Lift surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia, she had vertical breast lifts which moved her nipple-areolar complex upward by 6cms on the right and 7cms on the left. Concurrently 500cc high profile silicone breast implants were placed in the submuscular position

Breast Implant and Lift surgery result oblique view Dr Barry Eppley IndianapolisBreast Implant and Lift Surgery result side view Dr Barry Eppley IndianapolisHer three month after surgery results show good implant positions, adequately lifted breast mounds up on the implants and good symmetry. Her breast scars remain red as expected at this point after surgery and will take another six months to lose the red color.

This combination breast implant and lift surgery had about as good a result as could be expected for this type of body contouring operation. Whether she will ever need a revision will now depend on how the scars mature and appear later. But many such breast reshaping operations will not do as well nor should patients expect them to do so. There are many variables in this operation that make for less than perfect results. The national average for the need for a revision in combination breast implant and lift surgery is over 30%. The most common reason is that the breast tissue remains inadequately lifted and tightened around the augmented breast mounds…or has dropped off of them a bit as the tissues have relaxed in the healing process.

Highlights:

1) Breasts that have lost volume and sag usually need a combination of implant volume and a lift.

2) The breast reshaping combination of breast implants and a lift is a challenging procedure to achieve good symmetric results in a single operation.

3) The revision rates in combination implant and lift breast operations is high and averages over 30%.

Dr. Barry Eppley

Indianapolis, Indiana

January 15th, 2017

Cheekbone Widening Osteotomies

 

Cheek augmentation is most commonly done  by onlay augmentation. A wide variety of cheek implants exist to achieve almost every type of cheek dimensional in increase. And if a standard cheek implant cam meet the patient’s aesthetic midface needs, custom cheek implants can be designed for even the most exotic cheek augmentation change.

But some patients do not prefer the use of implants in the face and seek a more natural or autologous cheek augmentation method. Cutting and repositioning portions or all of the cheek bone can be done but its effects are more dimensionally limited. Just like the cheek bone osteotomy used to narrow the cheeks, it can be similarly done to done to widen.

Cheek Expansion Osteotomy Dr Barry Eppley IndianapolisA sagittal cut through the main body of the zygoma can be done from an intraoral approach. This maintains the anterior attachment of the zygomatic arch to the outer cortex of the zygomatic body. This cantilevered cheekbone segment can then be pushed out to increase zygomatic width and help there with a plate and screws. An interpositional autologous or cadaveric bone graft can be used between the segments if desired.

This cheekbone osteotomy method is used to widen or lateralize the outer cortex of the cheeks. It is a two-dimensional cheek augmentation technique that increases facial or bizygomatic width. However,  it can not increase anterior cheek projection. It has its value in certain aesthetic midfacial needs as well as in partial secondary correction of certain types of healed displaced cheekbone fractures.

Dr. Barry Eppley

Indianapolis, Indiana

January 13th, 2017

Congenital Symmastia Correction

 

One of the rare congenital breast conditions is symmastia. This condition is where the two breasts converge across the sternum eliminating the cleavage area and replacing it with the inner halfs of the breast mounds or a webbing. The name comes from Greek word derivation combining syn (together) and mastos. (breast)

While it is a well known complication from breast augmentation though disruption of the medial edges of the pectoralis muscle, as a congenital deformity it is very rare. Few cases have ever been reported and as a result no standard surgical treatment exists.

In the December 2016 issue of the journal Plastic and Reconstructive Global Open issue a paper was published entitled ‘Congenital Symmastia – A 3 Step Approach.’ In this described technique Liposuction was performed in the presternal area and the web between the breasts but was not extended beyond the lateral border of the sternum. An inframammary fold incision was made just 3 cm lateral to the midline of the sternum. Three quilting sutures were inserted in the intermammary area on each side of the midline between the dermis of the presternal skin and the periosteum at the lateral sternal border. After surgery a compression bolster was applied to the intermammary sulcus for several months on a continuous basis.

This approach to congenital symmastia correction includes three specific surgical manuevers. First excess subcutaneous tissue is removed between the two breasts which is most easily done with liposuction. Secondly the skin of the intermammary sulcus must be fixed down to the underlying periosteum by sutures either at the midline or at the lateral sternal border through the inframammary fold incision. It is almost always easier to place them at the lateral sternal border. The last step is postoperative compression for which there is no exact device/garment made for it. Various bolsters or bra modifications have to be devised.

Dr. Barry Eppley

Indianapolis, Indiana

January 11th, 2017

OR Snapshots – The Macroporous Custom Skull Implant

 

Custom skull implants have become a reliable and safe method of various types of skull augmentation. Made from the patient’s 3D CT scan, they cover the desired skull surface with a precise fit and a smooth outer surface that blends well into the surrounding bone/muscle areas. The most careful judgment has to be made in the thickness of its design so a competent and not overly tight scalp closure is obtained.

An obvious but often overlooked feature of most custom skull implants is that they are ‘large’. They can cover a significant surface area of the bony skull. This places an implant between the thick overlying scalp and the bone. While I have never seen this to cause any problems, it would be desirous to have some increased fibrovascular connections between the scalp and the bone. Since a silicone skull implant is not naturally porous this is not a biologic property such an implant would naturally have.

custom-skull-implant-ready-for-placement-dr-barry-eppley-indianapolisTo help achieve some integration of skull implants with the surrounding tissues, the concept of perfusion holes is used. This is were many 3mm to 4mm circular holes are placed through the implant. They can be thought of as ‘perfusion holes’. They will permit a very rapid tissue ingrowth through them, reconnecting the scalp and the bone with these tissue connections. They also serve to take one large implant pocket and make it many small pockets through this natural tissue quilting effect.

While these perfusion holes also help to fix the implant more securely into place, it does not make it any more difficult to remove or modify it later should the need arise. The tissue bands can be broken fairly easily in that process.

Dr. Barry Eppley

Indianapolis, Indiana

January 10th, 2017

The Custom Midface Implant

 

When most people (and many surgeons) think of midface augmentation, the use of cheek implants comes to mind. While cheek implants certainly do augment one area of the midface, they only cover one specific of the midface…the upper and outer corner of it.

Most of the midface lies between the cheeks and consists of the maxilla (upper jaw) and nasal base bones. From a bone standpoint midface augmentation is usually perceived as either a Lefort I or maxillary advancement (low midface) or a LeFort III osteotomy for a total midface advancement.

total-custom-midface-implant-dr-barry-eppley-indianapolisBut the midface can be augmented with implants just as effectively, or even more effectively, as moving the bone and way beyond what simple cheek implants can do. The use of a custom midface implant from a 3D CT scan can cover the entire midface from the pyriform aperture up to the cheeks. Such an implant can be inserted completely through an intraoral approach.

A custom midface implant is designed to increase central facial projection. It is an effective approach for patients with flat or concave facial profiles or for patients with negative orbital vectors. The point of maximum projection can be altered to either a low maxillary-anterior nasal spine point or higher up along the cheeks and infraorbital rims.

The typical ranges of increased midface projection for these custom implants is between 3mm to 7mms in most cases. Because it covers a broad surface area (the entire midface), its effect is greater than one would initially think.

Dr. Barry Eppley

Indianapolis, Indiana

January 9th, 2017

Supernumerary Nipple in Breast Augmentation

 

A extra nipple, in either men or women, is not rare. Occurring in up to 5% of the population, it is often mistaken for a mole due to its circular appearance. What separates it from a mole is that it is raised and has a textured and not a smooth appearance. It does not usually grow in size and only gets bigger in proportion to the body as it grows.

milk-linesThe location of a supernumerary nipple is also a giveaway as it will lie along the milk lines. The milk lines are embryonic vertical lines that extend from the armpit to the legs from which arise breast tissue and nipples. They appear early in embryonic life by the end of the second month in utero and well before sexual identity is formed. (hence why men have nipples even though they will never breastfeed) The nipples will form along this line and humans always have two nipples…although more are capable of forming along the milk lines.

In most cases of extra nipples, medically known as polythelia, it will just be a single one and is usually located below the breast or chest. Hence the term third or triple nipple. In more rare cases it will be more than just a nipple and it may develop into an actual breast mound albeit much smaller than a natural breast. (polymastia)

supernumerary-nipple-dr-barry-eppley-indianapolissupernumerary-nipple-next-to-augmented-breast-dr-barry-eppley-indianapolisGiven the relative common occurrence of an accessory nipple, it would not be rare to find it on a prospective breast augmentation. This is an example of a 35 year-old female who came in for breast implants and wanted to have a raised mole removed at the same time. Its appearance was clearly that of a nipple and not a typical mole. When removed at the time of surgery, its appearance can be seen to be similar to a nipple when laid up against the augmented breast.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Case Study – Asian Double Eyelid Surgery

 

Background:  The double eyelid surgery is a well known blepharoplasty technique that creates an upper eyelid crease in the typical Asian monolid. While the supratarsal fold is present in many ethnic groups around the world, it is missing in many Asian patients. The operation per we does not really create two upper eyelids or removes a single eyelid per se. But the placement of a crease creates two discernible upper eyelid sections which make it appear more interesting and even energetic.

While often called ‘westernizing’ the eyelid, this is not really the objective of the surgery nor is what most Asian patients want. Rather it makes the eye area more interesting than a monolid and is also a cultural sign of beauty. This accounts for its tremendous popularity in eastern Asian culture particularly amongst younger people.

There are a lot of variations in the Asian upper eyelid. It is common to see patients who have a hint or partial upper eyelid fold. Having some fold dictates where the new fold will be in most cases. Setting the new fold position can widely vary from its location above the lashline to its shape across the upper eyelid. There are numerous different techniques for creating the fold from no to a full incisional approach…each with their surgeon advocates.

Case Study: This 21 year-old female wanted double eyelid surgery to enhance her appearance. Her right eyelid was a monolid while the left eyelid had an incomplete crease, most promienently seen in the outer half of the lid.

asian-double-eyelid-surgery-intraop-dr-barry-eppley-indianapolisUnder general anesthesia, she had a full incisional double eyelid procedure using 5 points of levator-tarsal-dermal fixation for each eyelid. The crease height used was based on the of her incomplete crease level of the left upper eyelid. She declined medial epicanthoplasties. The immediate intra- and postoperative appearance can be striking with what appears to be creases that are too high.

asian-double-eyelid-surgery-results-front-view-dr-barry-eppley-indianapolisHer six months after surgery results show a pleasing upper eyelid appearance with defined creases and good symmetry between them.

Highlights:

1) Double eyelid surgery is an Asian eyelid procedure to make the upper eyelid more defined. (monolid to two distinct sections of the upper eyelid)

2) Many double eyelid procedures include treatment of the epicanthal fold as well. (medial epicanthoplasty)

3) Recovery from double eyelid surgery takes 3 to 4 weeks to see the final result

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Technical Strategies – Stacked Jaw Angle Implants

 

Jaw angles implants are designed to add size and shape to the mandibular ramus area. They are a companion and complement to the more commonly performed and well known chin implant. Together chin and jaw angle implants create a complete jaw augmentation approach.

While selecting the style and size of chin implants is fairly easy, doing so with jaw angle implants is not. Since the chin is a projecting structure on the edge of the jaw, the amount of horizontal projection is frequently the most important dimensional consideration. This is both easy to see, measure as well as perform computer imaging. Jaw angle implants, however, are not an edge enhancement procedure. Rather they provide augmentation to the side of the jaw/face where measurements and even computer imaging is harder to do in a reliable fashion.

Because of the more imprecise nature of jaw angle implant size selection, it is very helpful to be prepared during surgery with multiple implant sizes. Most of the time standard sizes will work (small, medium and large) but this is not always the case. How an implant looks in place can be less than what one would anticipate and there is always the issue of asymmetry which is very common in the jaw angle area.

stacked-jaw-angle-implants-technique-dr-barry-eppley-indianapolisIf necessary it is always possible to stack jaw angle implants together to create the desired augmentation effect. Unlike many other facial implant types, angle implants fit together fairly well… a little bit like nesting dolls. Some trimming does need to be done but the implants can be stacked fairly securely. This will increase the width of the jaw angle augmentation over what any one single implant can do.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Zygomatic Arch Implants and the High Cheekbone Look

 

zygomatic-arch-sumental-viewThe zygomatic arch is the part of the cheekbone that extends back to the temporal bone in front of the ear. It is a thin bone and serves and looks like a bridge, allowing the temporalis muscle to pass underneath it. It can be thought of as the side of the cheekbone.  While it looks like a solid bone close inspection reveals a suture line in its middle, signifying it is formed by the union of the temporal process of the zygomatic bone and the temporal process of the zygomatic bone.

The word, ‘zygomatic’ is derived from the Greek word zygoma meaning bolt or bar….to join. The term has been used since ancient times and the arch part of the zygoma certainly joins the cheek to the temporal bone.

female-high-cheekbone-lookmale-high-cheekbone-lookWhile this facial bony anatomy is interesting, it is relevant in aesthetics to the structural basis of the high cheekbone look. This often exaggerated look to the cheeks creates a distinct line along the sides of the face. It is often seen in many male and female models and is a desirous facial feature for many patients seeking an improved and more symmetric facial appearance.

While numerous styles of cheek implants are available, none of them are designed to actually create the complete high cheek bone look. While they all add increased volume to the zygomatic body, none has any extension back along the zygomatic arch…which is the key to high cheekbone look.

large-zygomatic-arch-implants-design-dr-barry-eppley-indianapoliszygomatic-arch-implant-dr-barry-eppley-indianapolisZygomatic arch implants are designed to be used alone or in conjunction with standard cheek implants to create the high cheekbone look. These implants help to create an augmentation ridge from the cheekbone below the side of the eye back to in front of the temporal bone in front of the ear. Their posterior lengths can be adjusted to either stop in front of the temporal hairline or go back further into it.

When placing zygomatic arch implants it often takes more implant size than one would think. More than a few millimeters in height and width are needed in most cases.

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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