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.
December 3rd, 2016
Background: Osteomas are the most common bony tumor of the craniofacial skeleton. They are benign bone growth that is typically seen growing on another piece of bone. They appear as an outcropping or ‘mushroom’ of slowly growing bone and are easily disinguishable by appearing as a hard bump on an otherwise smooth bone surface. This makes them very identifiable on the skull where such bumps appear evident even when they are small.
Their are various causes of osteomas but the most common one is a history of prior trauma. Low impact blunt trauma to the skull is common since the head is a large object that frequently is inadvertently hit. If the head is struck in just the right location with enough force a perforating blood vessel may bleed and create an external bruise.When blood gets under the periosteum it can serve as a trigger for bone growth.
Case Study: This 56 year-old female had a large bump of the left brow bone that began over 17 years when she was accidentally struck by an attic door on her forehead. She developed a large bruise from which a small bump eventually grow to the big bump now seen. It has finally gotten big enough that she could no longer hide it. A CT scan showed that it was an outcropping of bone emanating from the outer cortex of the brow bone.
Under general anesthesia the brow bone osteoma was approach through a hairline (pretrichial) incision directly above it. Through a subperiosteal tunnel of the forehead skin the osteoma was exposed and dissected off of the overlying scalp tissues and the supraorbital nerve. An osteotome was used to separate it from the normal surrounding bone. The osteoma was composed of poorly calcified bone that was softer than normal skull bone.
The removal of forehead osteomas are often dramatic as the removal of a large bump on the upper face resumes a normal appearance. The removal of a benign bony tumor should be done, if possible, through a discrete incision to avoid creating any adverse aesthetic trade-offs. Incisional approaches include a direct incision (right over it) and the remote approaches of a pretrichial or scalp incision.
1) Osteomas are benign bony tumors that are common in the craniofacial region.
2) Forehead osteomas are often the result of prior trauma and are slow growing over many years.
3) Forehead osteomas can be removed through either a hairline incision or an endoscopic approach further back in the scalp.
Dr. Barry Eppley
December 1st, 2016
Background: Breast implants are known to have a limited lifespan due to potential disruption of the implant shell. But as long as the implant shell remains intact the volumetric effect of the implants persist. Yet while breast implants remain stable the long-term effect of the appearance of the breast changes many years or decades later.
Whether a woman has an implant in or not, the breast tissue and skin envelope changes. Breast tissue may be lost and the skin will develop some sag. This effect is accentuated with pregnancies and weight gain/loss. The presence of implants may delay or blunt these body-related changes but they almost always occur. Over time the natural breast tissue may slide off of the implant as the tissues weaken and the breasts will look much less perky.
With these breast changes women may seek to exchange their breast implants for larger ones to get a breast rejuvenation effect. The question is what size increase is needed to see a visible change.
Case Study: This 44 year-old female had 350cc saline breast implants placed twelve years ago. She had two subsequent children and then lost some weight as she became much more of a fitness enthusiast. While her saline implants remained intact her breasts had developed some sag and she felt they had lost overall size. She wanted new breast implants that produced a dramatic change in implant size and upper pole fullness.
Under general anesthesia through her existing areolar incisions, her saline implants were removed and replaced with 700cc ultra high silicone implants into her existing submuscular pockets.
When replacing breast implants for a larger and fuller look, it takes more increased volume than one would think. Of course it depends on what final breast size one wants but anywhere from a 50% to 100% volume increase is needed. That could be anywhere from 150 to 300ccs for most women.
1) As long as breast implants remain intact, they maintain a persistent volume.
2) The tissue around breast implants does change over time through some loss of volume and tissue sag off of the implants.
3) To re-expand saggy breasts with new implants a much larger breast implant size must be chosen than one may think.
Dr. Barry Eppley
November 30th, 2016
A gummy smile or excess gingival exposure is well known to be the result of vertical maxillary bony excess. Corrective methods include a maxillary impaction procedure or soft tissue lowering gummy smile procedures. Both approaches have their indications and are most commonly used in Caucasian patients.
In the December 2016 issue of the Annals of Plastic Surgery an article entitled ‘Correction of Midface Depression Using An Inverted M-Shaped Expanded Polytetrafluoroetylene Implant Improves Gingival Exposure’. The authors have previously observed a correlation between gingival excess and midfacial depression in Asian patients. Over an eight year period they treated 42 patients with excessive gingival exposure with varying degrees of midface depression with an inverted M-shaped ePTFE implant placed at the base of the pyriform aperture at the bone level.
Based on before and after pictures as well as measurements of upper lip length, nasolabial angle, and facial convexity angle, the results of the midface implant was assessed. The average maximum gingival exposure was around 5.5mms (± 1.5 mm) before surgery which was significantly decreased to less than 2mms at 6 months after surgery. The nasolabial angle was improved from 85° to 95° in some patients. Most patients rated their postoperative results as highly improved. Temporary and typical postoperative findings were upper lip numbness, foreign body sensation, and a stiff smiling. These symptoms resolved after three months. No infections or implant extrusions were seen.
This paper shows that in cases of midface depression excessive gingival exposure can be reduced by pyriform aperture implant augmentation. This approach appears to offer a safe and effective treatment option with a high level of patient satisfaction.
Dr. Barry Eppley
November 29th, 2016
Background: An aesthetically displeasing size of the head can occur at various skull areas. One such area is at the side of the head most commonly located above the ears. When it is too wide there is a noticeable convexity or bowing out of the temporal region above the ears. A more aesthetically pleasing shape at the side of the head is more of a straight line or one with a minimal convex shape to it.
Because the temporal region is located on the side of the skull it is logical to assume that it is bone and can only narrowed by bone reduction. But careful analysis of many CT scans reveals the thickness of the posterior temporal region above the ears is about 50:50 bone and muscle. The thickness of the posterior temporal muscle is a lot thicker than most would think. In men it is 7 to 9mm thick while in women it can be 5mm to 7mms thick.
Thus removal of the posterior temporalis muscle offers an effective treatment strategy for narrowing the side of the head. It can also be done with less scar that would be required for temporal bone reduction.
Case Study: This 36 year-old male wanted to reduce the fullness on the sides of his head. A CT scan revealed that the side of the head above the ears had a sufficiently thick muscle layer that could allow for a significant reduction.
Under general anesthesia a straight 5 cm long scalp incision was made just above the ears. The temporalis fascia was split through which the entire posterior temporalis muscle was removed. Closure of the incision made for an inconspicuous scar line.
Bilateral removal of the posterior temporalis muscle bellies changed the shape of the sides of his head from convex to straight. With muscle thicknesses that average 7mms, bilateral removal can result in a transverse head width reduction of up to 1.5 cms. This demonstrates that temporal bone removal may not be necessary to achieve a visible head width shape change.
1) The wide side of the head is aesthetically determined by an increased convexity above the ears.
2) An increased head width above the ears is caused by both increased bone thickness and muscle thickness.
3) Head width or temporal reduction is best done by removal of the entire belly of the posterior temporal muscle.
Dr. Barry Eppley
November 28th, 2016
There are numerous options for elective plastic surgery of the male genital region. Various penile lengthening and enlargement procedures, testicular implants and scrotal lifts are all options for the man who seeks penoscrotal enhancements.
The size of the scrotum is largely determined by what lies within. The size of the testicles is largely responsible for the scrotal sac size. But the size of the testicles can not be increased naturally through hormone supplementation or other non-surgical methods. There is the concept of wrapping a shelled out testicular implant around the existing testicle to increase its overall size as one surgical option.
The other surgical option for scrotal enlargement are fat injections. Just like fat injections are used all over the body for soft tissue augmentation, they can be safely inject intothe scrotum as well. The scrotum is not known as a large repository of fat but it does have fat amongst its various tissue layers.
Given its relatively small body size and the low volume of fat that need to be injected, fat survival in the scrotum would be expected to be high. Using blunt cannulas and low pressure injection, fat can be safely placed through the scrotum without injury to testicles or the vas deferens.
Besides scrotal enlargement, one other invaluable use of fat injections to the scrotum would be in preparation for testicular implant placement when one has had prior irradiation. Fat injected into tissues that have been irradiated is well known to improve its vascularity and make it more amenable to surgical manipulation with a lowered risk of healing and infectious complications.
Dr. Barry Eppley
November 26th, 2016
The use of implants for chin augmentation is the most popular method to achieve enhanced projection of the lower face. Many materials have been used for chin implants and today it usually comes down to the use of either a silicone or Medpor material. There are surgical advocates for both types of chin implants and both can be successfully used under the right circumstances.
Where silicone and Medpor chin implants differ dramatically and unequivocally is if the patient wants the implant removed. The aggressive tissue ingrowth into the Medpor material makes its removal difficult and fairly traumatic to the surrounding tissues. I have read some surgeons who say the material can’t be removed. This is not true, it is just that it is much more difficult than the easy removal of silicone implants.
If a Medpor chin implant is removed, there is often the need to replace it. The question is what should that be. That depends on why the implant was originally placed, its size and shape, and what the patient’s aesthetic goals.
In this example a small petite female with a very short chin and high jaw angles had a Medpor chin implant placed. The implant produced numerous adverse aesthetic sequelae including a wide and elongated chin. Through an intaoral approach the Medpor chin implant, which was secured by 6 screws, was able to be removed in many pieces. The tissue ingrowth of the wings of the implant had adhered to the mental nerves which required careful separation to avoid nerve avulsion. The chin augmentation replacement was a sliding genioplasty. This brought the chin forward, made it less wide and vertically shortened it as well.
While chin implants are made of different materials, their effectiveness is best determined by the selection of implant style and size. It is important that chin augmentation in females is seen as aesthetically different than that of men. The type of chin implant style that works well in men often does not in females.
Dr. Barry Eppley
November 26th, 2016
Septal perforations are a risk of any nasal surgery in which septal cartilage is removed. Whether it is done for correcting a septal deviation or harvesting a septal graft for support in rhinoplasty surgery, loss of the cartilage ‘wafer‘ between the two sides of the mucosa risks a through and through defect to occur
While not all septal perforations are symptomatic or need repair, when they do they are very challenging to do successfully. The many methods described for septal perforation repair from synthetic buttons to grafts, and their varying rates of success, speak to this challenge.
In the November 2016 issue of JAMA Facial Plastic Surgery, an article was published entitled ‘Use of Costal Perichondrium as an Interpositional Graft for Septal Perforation Closure’. In 51 nasal septal perforation patients, the use of costal perichondrium as an interpositional graft with bilateral mucosal flaps was used for the repair. Forty-four (44) of these patients actually underwent closure with this technique which was successful in 42 patients (95%) over an 18 month followup period. Regardless of the septal perforation size treated, costal perichondrium as an interpositional graft aided in the rate of successful closure of the treated septal perforations.
While the technique and experience of the surgeon should not be minimized in the treatment of the septal perforation problem, what is it about costal periochndrium that may make it better than other autologous or allogeneic grafts? Since it requites a small chest incision to harvest it had better have some favorable biologic characteristics.
Costal cartilage is a composite structure composed of cartilage surrounded by a dense tendon-like perichondrium. Costal perichondrium is very different than nasal perichondrium because it is much thicker as it provides some mechanical benefits to the ribcage. Studies have shown that it adds up to 50% more resistance to bending forces across the costochondral junction. This stoutness means it is thick, can hold sutures if needed and be more quickly revascularized than thinner fascial or thicker cadaveric dermal grafts. This means that it may hold up well even if the mucosal flaps break down.
Dr. Barry Eppley
November 26th, 2016
Muscle augmentations are done throughout the body using a variety of soft solid silicone implants. The arm is no exception as bicep and tricep augmentations are done by placing the implants on top of the muscle but under the fascia through small armpit incisions.
But not every male who desires bicep augmentation wants to have an implant placed. The other alternative is a natural one using one’s own fat. Soft tissue augmentation through fat injections is now a well recognized procedure. It offers an increase in soft tissue volume, like the size of a muscle, that is directly dependent on how much fat is injected and how much fat survives.
Whether bicep augmentation can be done by fat injections also depends on how much fat one has to harvest. Using the ‘halving principle’ of fat injection outcomes, 50% of the fat that is harvested is lost by concentration and another 50% is lost by resorption after injection. Since the typical bicep implant is in the range of 100cc to 200cc in size, it would require around 1500cc of liposuction aspirate to achieve a similar result using fat.
Bicep augmentation by fat injection is really reserved for those men who are already having some significant liposuction done. While the upper arm bicep region is a relatively small body area, it still requires more injected fat volume than one would initially think.
Dr. Barry Eppley
November 24th, 2016
Background: The natural oblong and round shape seen in many pictures and diagrams of the skull is not enjoyed by everyone. Many people do have various lumps, bumps and asymmetries of their skull that has developed for a variety of reasons. These are most commonly the ‘blueprint’ of their skull shape determined by their genetics and shaping forces in utero during development.
Such skull asymmetries today are much more likely to be seen in men. This is due to hair loss patterns and the now widely accepted look of having a shaved head or very closely cropped hairstyles. What was once hidden by hair can be uncovered as the hair is lost, exposing the natural shape of the skull. In more significant cases the head shape can be a mixture of hills and valleys and can be a source of aesthetic discomfort for some men.
An irregular skull surface on a male historically can be a difficult aesthetic problem to treat by bone contouring methods. Between a larger scalp scar and the need to intraoperatively apply various bone cements, the aesthetic results may not have justified the surgery. But today’s use of 3D CT implant designs have made skull recontouring more aesthetically pleasing.
Case Study: This 36 year-old male wanted to improve the appearance and feel of his skull. He was bothered by its shape with one side being flatter than the other and the upper part of the back being flat. Using a 3D CT scan a custom skull implant was designed to make his head have a rounder and more symmetric shape. The implant was not overly thick being 5mms at it thickest portion with feathered margins around all of its edges.
Under general anesthesia a curved 9 cm long scalp incision was made. Wide subperiosteal undermining was done along the outlines of the implant’s design. The implant was able to be inserted due to its thin and flexible. Great care was taken to ensure that the implant was positioned properly and all edges were unfolded and flush with the skull’s surface. Small microscrews were used to tack down and stabilize the implant.
Custom skull implants do not have to be large and are often smaller than one would think. For the patients who has some skull irregularities, obtaining a smooth skull shape often requires an implant design that is thin but evens out the outer skull contour. The use of 3D designing from a CT scan makes this possible.
1) Asymmetries in the shape of the skull are not uncommon and are usually due to congenital origins.
2) The male who shaves his head or has very closely cropped hair often unmasks various skull asymmetries.
3) A custom skull implant made form a 3D CT scan is the most assured way of improve skull asymmetries with the least amount of scalp scar.
Dr. Barry Eppley
November 21st, 2016
The tear trough deformity has become well recognized today and is a natural consequence of the attachments of the lower eyelids and infraorbital rim bone. Originally called the nasojugal fold, it is a sulcus that runs downward and outward from the inner corner of the eye. It is formed by the fascial attachments to the periosteum at the orbital rim between that of the orbicularus oculi and upper lip muscles. This creates a hollow area under the eye that often appears as a dark circle.
Tear troughs become magnified with age and particulalry with poor underlying skeletal support. Recessed orbital rim bone makes tear troughs look deeper and allows lower orbital fat to appear as if it is prolapsed or herniated.
The most popular treatments for tear troughs are injectable fillers and, as an isolated procedure, can be very effective. Surgical treatments for tears trough come into play usually because a lower blepharoplasty procedure is being done for an overall periorbital improveent.These include a variety of fat grafting techniques as well as implants.
The well known silicone tear trough implant was developed over two decades ago to avoid the problems with free and pedicled fat grafts. They are most commonly placed through eyelid or intraoral incisions. Available in differing sizes they are placed along the infraorbital rim staying above the infraorbital nerve foramen. Their placement requires a full arcus marginalis release. The best method to ensure permanent implant placement is small microsrew fixation to the bone. (only the subciliary eyelid incision allows this to be done)
Dr. Barry Eppley