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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.

November 20th, 2017

OR Snapshots – Silicone Testicle Implant Replacement

 

Testicle implants have been used for decades in various forms. It is the only known surgical method to replace the lost volume and shape occupied by a natural testicle. Originally they were composed of solid silicone but that material was removed from commercial availability as a result of the silicone breast implant issues in the early 1990s. They were subsequently replaced by saline-filled implants, a dubious choice for the scrotum, but was the only implant material available at the time.

Newer custom testicle implant devices are now available on an individual patient basis. They are much softer than that of saline implants and have no risk of implant deflation. Because they are done on a custom basis the size options are much greater and better size matches to the opposite side now exist.

In almost all cases of testicle implant replacement that I am asked to performed, due to size and feel issues with the indwelling implant, a saline testicle implant is encountered. But in a most recent case of a twenty-five year old implant replacement, an old silicone implant was encountered. It was smaller than the opposite side and was very highly positioned. It also had a mesh patch on one of its ends presumably to encourage tissue adherence/fixation…wbich it clearly had done with an adverse aesthetic effect. (highly positioned and a feeling of intermittent tugging) Its custom replacement was 25% larger, made of a much softer solid silicone material and a new pocket was made much lower in the scrotal sac.

Their is a long history in testicle implants of wanting to fix the implant into position. This is a curious implant technique as it can be the cause of a high implant position and some level of chronic discomfort. This harkens back to the early of breast implants when various methods were used to fix the implant to the chest well. Like a breast implant, a testicle implant should be allowed to float freely and let it seek its own natural low position in the scrotal sac.

Dr. Barry Eppley

Indianapolis, Indiana

November 20th, 2017

Case Study – Transgender Tracheal Shave Based on Head Extension

 

Background: The  prominence of the Adam’s apple (hyroid cartilage) in the neck is a distinct gender-associated feature. In males, just like the brow bones, it is more protrusive than females due to the growth influence of testosterone on its cartilaginous development. This is why in facial feminization surgery, particularly in the male to female transgender patient, a tracheal shave is often done.

But not all tracheal cartilage protrusions are seen in a normal head posture position. Its prominence may be partially or fully masked by a low cervicomental angle, a fatty neck or a highly positioned thyroid cartilage. In some cases it is not fully revealed until the head is extended. While this always makes any Adam’s apple more prominent as the neck tissues are pulled back around it, the revealed prominent thyroid cartilage in the transgender patient can still be bothersome.

Most tracheal reductions or tracheal shaves are done through a small horizontal skin incision over it. In this operation it is the laryngeal prominence (this is what makes up the true Adam’s apple) of the paired thyroid cartilages that is removed. The laryngeal incisura is the most anterior part of the laryngeal prominence and this must be flattened through cartilage shaving. It usually can not be reduced  back to the same horizontal projection as the inferior thyroid notch to prevent cartilage instability and potential mucosal violation and even disruption of the vocal cords.

Case Study: This young transgender male to female patient was bothered by the prominence of the Adam’s apple which was most noticeable when the head was extended. It was such less obvious with the head in neutral position and was largely naked by the lower cervicomental angle.

Under general anesthesia a small horizontal skin incision was made over the greatest prominence of the Adam’s apple. The strap muscles were separated in the midline and the Adam’s apple cartilages exposed. Their horizontal projection was reduced by vertical  cartilage shaving almost back to the level of the projection of the cricoid cartilage. The strap muscles were reapproximated and the skin closed.

The immediate intraperative result was apparent. Even though the neck profile was not completely flat its forward projection was similar to what a female’s neck with their head in extension would look like.

Highlights:

1) A prominent Adam’s apple can only be fully revealed in some patients by neck extension.

2) In the transgender tracheal shave patient any prominent neck protrusion, neck extended included, may appear masculinizing.

3) In surgery the neck is extended to maximize the amount of tracheal reduction done.

Dr. Barry Eppley

Indianapolis, Indiana

November 19th, 2017

Long-Term Results in Calf Implants

 

Calf augmentation is most commonly done with implants. There are a variety of reasons patients pursue augmenting the gastrocnemius muscle from congenitally thin legs, muscle atrophy due to disease or trauma and the desire for larger calfs that exercise and effort alone can not easily achieve.

While injection fat grafting is another option for larger appearing calfs, its volume retention is not assured unlike that of calf implants. Placing an implant underneath the investing crural fascia of the muscle has been done for decades and offers a better aesthetic result with less complications than a subcutaneous implant location would.

But despite the success of calf augmentation with proper surgical technique, it is not commonly performed by most plastic surgeons. This is undoubtably because it is infrequently requested and, as a result, it is very hard for a surgeon to develop much experience with this type of body implant surgery.

In the October 2017 issue of the Aesthetic Surgery Journal, an article entitled ‘Calf Augmentation and Restoration: Long-Term Results and the Review of the Reported Complications’. The authors reviewed their 25 year experience with calf implant augmentation in 50 patients. (60 calfs) Indications were aesthetic in 23 patients, six were bodybuilders, and 21 underwent lower leg reconstruction because of deformity caused by illness. Their results based on surgeon evaluation had good to excellent results obtained in 30 out of 37 implanted patients. (81%) Patients rated their results as acceptable to good in 35 out of 37 patients. One very serious complication occurred in a bodybuilder who developed compartment syndrome in one leg leading to the necrosis of muscles. The authors report other complications as minor and manageable.

This series of calf implants shows that it can be a successful and low complication body contouring procedure. From a medical complication standpoint, infection is always a risk with an implant but that appears to be fairly low in a pocket that is partially lined may muscle. The devastating complication of compartment syndrome has rarely been reported but it is easy to see how it is possible…the use of four implants (two in each leg, medial and lateral muscle bellies) on top of already large calf muscles. This can potentially impair arterial inflow and one must always be on guard for its prevention.

Dr. Barry Eppley

Indianapolis, Indiana

November 19th, 2017

Case Study – Posterior Temporal Reduction for the Wide Head

 

Background:  The side of the head is an often overlooked aesthetic area whose shape can really only be appreciated in the frontal view. While great attention is paid to the anterior temporal region by the side of the eye due to its facial proximity, the more obscure posterior region is seen back in the hair-bearing temporal region above the ear. It doesn’t have much topographic variation other than an overall linear or more rounded shape. With hair it is hardly noticeable at all.

But in the man whose has very closely cropped hair or shaves his head, all areas of the head become more aesthetically important. The shape of the side of the head achieves an awareness not previously seen. While there are no established aesthetic standards for which its shape should be, an excessive amount of convexity to it s usually deemed unaesthetic.

In determining how to reduce excessive fullness on the side of the head the pertinent question is what makes it so. While often believed to be a bone problem, and the bone does make some contribution to it, it is equally if not more than made up of the temporals muscle. The thickness of the posterior temporals muscle can be surprisingly thick particularly around the top of the ear.

Case Study: This young male was bothered by the convexity on the sides of his head above his ears. While he felt this head overall was too big he was most bothered by the fullness on its sides.

Under general anesthesia the resection of the posterior temporals muscle was approached through a small vertical incision just above his ears. The entire posterior muscle mass was removed behind a vertical line going up from the ear but leaving the overlying fascia intact.

When seen years later, the healing of the scalp scar was remarkably faint. The reduction in the fullness of the sides of the head was apparent and had changed from a bowed out shape to a straight line.

Temporal reduction is an effective procedure for reducing the fullness on the sides of the head. It is a myectomy-based procedure that does not incorporate any bone reduction achieve its effects. It causes no jaw movement or chewing dysfunction. The procedure has evolved today to one that places the incision behind the ear in the postauricular sulcus so it is essentially ‘scar-free’.

Highlights:

1) A wide side of the head is caused partially by the thickness of the posterior belly of the temporals muscle.

2) Resection of the posterior temporal muscle is an effective technique for reducing the convexity on the side of the head.

3) Removal of part of the temporal muscle does not cause any long-term jaw movement restrictions.

Dr. Barry Eppley

Indianapolis, Indiana

November 19th, 2017

The Safety and Effectiveness of Perioral Mound Liposuction

While liposuction is widely used over many body areas, its applications to the face are much more limited. Between the far fewer isolated fat pockets and the location of motor nerve branches, facial liposuction is a fairly limited technique for fat reduction outside of the neck.

One facial area that can have liposuction done is that of the perioral mounds. As the name implies, it lies to the side of the mouth. It is an area of subcutaneous fat that lies between the skin and the buccinator muscle. It is often confused with that of the buccal fat pads and is a primary reason that buccal lipectomies can be unsuccessful due to a misdiagnosis. The buccal fat pad is a discrete encapsulated fat pocket that sits right under the cheekbones but does not extend down to the horizontal level of the mouth. (except in the rare instance of buccal fat prolapse)

The pooches or mounds besides the mouth can be a source of aesthetic dissatisfaction. While they can occur in faces of all sizes, they equally occur in thin faces where it is harder to imagine such a discrete fat collection could occur. Why they develop is not known but time fat is needed in this area to separate the underlying muscle from the skin.

Perioral mound liposuction is often viewed as not possible or safe due to facial nerve branches.  But an anatomic analysis of this area shows that there are not facial nerve branches in this part of the face. The nerve free zone of the lower face is below a line drawn from the earlobe to the mouth corner, a vertical line than drawn down to the jawline and the jawline traced posteriorly back up to the earlobe. The perioral mound area lies in the anterior half of this demarcated facial region.

Perioral mound liposuction is performed with a small cannula through a mucosal incision just inside the corner of the mouth. Fat is removed above the buccinator muscle in a fan-like fashion from the mouth corner. It takes some time and persistence to work the area as it is not like that of larger fat areas like the abdomen. It is a smaller more fibrous fat collection which is measured in single digit cc volumes.

Fat removed from the perioral mounds can be strained and measured. The volume removed is usually between 2 to 3ccs of fat per side. That may not sound like much but is all it takes to reduce a prominent facial fat mound.

Perioral mound liposuction is a safe technique for selective facial fat reduction. Having performed the procedure in over 50 patients, no case of facial nerve weakness has ever occurred. While small in volume extraction it is effective for the discrete subcutaneous fat collection by the sides of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

November 16th, 2017

OR Snapshots – Custom Sterno-Pectoral Implants in Pectus Excavatum

 

The chest is exposed to a variety of deformities of its bony and cartilaginous structures. The curve of the ribs around the chest and their attachment to the sternum create an architecture that can become disturbed. One of the most recognized of these deformities is pectus excavatum. This chest wall deformity is most typified with the sunken appearance of the lower end of the sternum. This is associated an outerward flare of the lower ribs and a broader concavity of the upper rib cartilages. Despite the basic anatomic components of pectus excavatum, it comes in a wide range of presentations. It is not always symmetric and can appear just one side.

Surgery for correction of pectus excavatum has been around for decades. It has evolved from open rib resections to the placement of metal bars behind the sternum to create an outward push for a chest wall reshaping effect. But many of these procedures are helpful they rarely provide a perfect correction. And the invasiveness of surgery, particularly in younger patients who have a lot of growth to undergo, can led to their own chest wall abnormalities as well.

In adults residual sterno-pectoral chest wall deformities can be treated by the placement of implants to improve their contours. While in the past such chest wall implants have been made by a variety of different methods and materials, a custom approach is used today. This can be done by either a direct moulage on the patient’s chest from which the implant is made or the implant can be made directly from a design done on the patient’s 3D CT scan of their chest.

Because of better design methods, more complete sternal or larger sterno-pectoral implants are now possible. Bigger designs of course requirer larger incisions to insert. But often pre-existing scars make this less of an aesthetic concern.

Dr. Barry Eppley

Indianapolis, Indiana

November 14th, 2017

Case Study – 2nd Stage Custom Skull Implant for Crown Augmentation

 

Background: Deficiencies of the crown area of the head are unique to females. They often compensate for such skull height deficiencies through hair style camouflage techniques. Two definitive treatment is a custom skull implant made from a 3D CT scan.  While not being able to add unlimited increases in skull height due to the limitations of the stretch of the scalp, they do provide the most effective skull augmentation method know today.

When women consider implant augmentation of the crown and surrounding skull areas, the question is always how much additional height/fullness can be obtained.While every patient’s scalp is different, as a general rule a one-stage skull implant will probably create 50% to 75% of the result many women really want. Much more of a result or even their dream result often requires a two-state approach to achieve. (first stage scalp pander and second stage implant)

But for a variety of reasons, some women may have to opt for a one-stage skull implant even though they know that their skull augmentation result will not be ideal. But this does not mean further augmentation may not be possible later.

Case Study: This middle-aged female had a custom skull implant placed one year earlier for crown augmentation. Her initial implant had 9mms of central projection over the crown. She now desired for augmentation and a new implant was made that doubled the central projection to 18mms.

Under general anesthesia her original scalp incision, which had healed beautifully, was reopened and the implant exposed. The capsular tissue could be seen to e adherent to all of the original perfusion holes which has been placed through it. The implant was separated from these scar bands and removed. It was replaced with the new casual implant whose height increase could be fully appreciated when laid side by side. The scalp closure was tight but secure over it.

Patients can be initially content with their skull augmentation result but grow desirous of more as they accommodate to the change. Or that may chosen the one-stage approach for practical reasons, hoping it will be enough but are that it might not be. Either way, an indwelling  skull implant does act as a tissue expander for which s larger implant can be successfully placed later.

Highlights:

1) For additional crown of the skull augmentation effect, a second custom skull implant can be placed after the first one.

2) An indwelling skull implant acts as a tissue expander, allowing for a second large implant to be placed that would not have fit the first time.

3) Doubling the central area of projection can usually be safely achieved in the second custom skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

November 13th, 2017

Fat Injections for Improving Breast Cleavage (Intermammary Distance Reduction)

 

The breast has many aesthetic features of which the sternal gap is one of them. The distance between the breasts is most commonly a consideration in breast augmentation surgery in an effort to create improved cleavage. But it can also be an issue in other forms of aesthetic breast surgery as well including breast lifting/reduction as well as in breast reconstruction.

Short of what an implant can do, reducing the distance between the breasts across the sternum requires soft tissue augmentation. Fat injection grafting offers an ideal method to do so. Fat grafting to the breasts has an established history although it has been typically applied in larger volumes for a breast augmentation effect.

In the November 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Breast Cleavage Remodeling with Fat Grafting: A Safe Way to Optimize Symmetry and to Reduce Intermammary Distance’. In this clinical series the authors treated eighty-six (86) patients who underwent various types of breast reshaping surgery. Fat injections were done in the medial pole of the breasts to reduce the degree of separation across the sternum or for medial pole asymmetry. Before and after intermammary distances were measured before and after surgery.

Their results showed a significant reduction in the mean intermammary distance from an average 3cm to a 1.7cm distance at one year after surgery. Only one fat grafting complication occurred which was an oil cyst that required aspiration.

Submuscular breast implant augmentation offers an ideal time to create improved cleavage by fat injection grafting. The breast tissue above the muscle remains unaffected by the submuscular pocket and does not connect with the implant pocket. For those women with widely spaced breasts who are undergoing breast augmentation surgery, fat injections offers a reliable method to enhance their cleavage as well.

Dr. Barry Eppley

Indianapolis, Indiana

November 12th, 2017

Case Study – Surgery for Mandibular Cherubism

 

Background: Cherubism is a very rare genetic disorder that primarily affects the shape of the lower jaw bone. The painless ‘swelling’ of the lower jaw creates a fullness that appears like an extreme form of mumps and. as a s result, the chubby facial appearance is equated to that of cherubs as often seen in paintings of biblical times and the heavens.

The facial chubbiness comes from the overgrowth of the jaw. The patient’s face becomes enlarged and disproportionate due to the fibrous tissue and atypical bone formation. It creates expansile growth of the ramus of the mandible primarily. It expands out both sides of the cortical covering of the ramus and replaces it with fibrous tissue and cyst-like formations. The reason that this extensive fibro-osseous growth occurs is not known but an imbalance between the normal osteoclastic and osteoblastic remodeling of the bone with growth is altered. It has been linked to a genetic mutation of the SH3BP2 gene on chromosome 4p16.3.

It is an autosomal dominant disorder which occurs primarily in males. It usually appears in childhood at around age 5 or 6. It will continue to grow until puberty when many affected patients stabilize and the abnormal bone growth ceases. In more mild cases the expanded bone may return to a normal bone shape and facial appearance. But in more moderate and severe cases this does not occur. In more severe cases the jaw growth goes unchecked and continues to deform the face.

The only treatment for cherubim is surgical excision of the affected bone. The cortical bone separates easily and exposes the now fibrous and cystic diploid space. Care must be taken in removing this soft soupy fibrous tissue to not injure unerupted teeth and the inferior alveolar nerve.

Case Study: This 7 year-old male child presented with a slowly progressive chubby face. His mother knew exactly the cause since there was a family history of cherubim. She herself was affected in a more moderate fashion which regresses to normal during her teenage years. A 3D CT scan showed the classic expansion of the cortices of the rams of the lower jaw with soft tissue formation between the two sides. The cortical expansion was fairly equal on both sides. The mother wanted him treated because of his appearance and feared it would get much worse.

Under general anesthesia an intraoral approach was used through a vestibular incision to access the enlarged outer ramps of the mandible. The outer cortex of bone was removed with a reciprocating saw to expose the soft gelatinous content inside. Curettes were used to scrape out the softer tissue, being careful to not injure the nerve which was exposed. All bony edges were then smoothed down and Tisseal adhesive was used for hemostatic over which the mucosa was closed with reservable sutures.

Cherubism is rarely seen let alone surgically treated. Surgery to do a subtotal resection  of the excessive fibro-osseous tissue is a low risk procedure that may either prevent further disease progression or hasten an earlier resolution of it.

Highlights:

1) Cherubism is a very rare cranofacial disorder that primarily affects the lower jaw.

2) Surgical treatment may be indicated when the degree of facial disfigurement is  source of emotional distress and is progressive.

3) Intraoral subtotal resection of cherubism is the preferred technique to avoid external facial scarring.

Dr. Barry Eppley

Indianapolis, Indiana

November 12th, 2017

Case Study – Adult Microtia Ear Reconstruction with Synthetic Framework

 

Background: Microtia is a well known congenital ear deformity where the external ear has variable amounts of underdevelopment. It is not that rare of a facial deformity affecting about 1 in 10,000 births. While it can occur in both ears, it more commonly affects one side of which it occurs far more frequently on the right side.

Microtia is almost always treated, at least in the U.S., in childhood. Its reconstruction is done by two basic methods in children, a completely autologous rib graft method and a combined synthetic ear framework covered by an autologous fascial flap-skin graft. There are surgical advocates for each ear reconstruction method and each one has its own distinct advantages and disadvantages. In children the use of a synthetic ear framework and rib graft  methods is probably about equally divided.

Adult microtia is very rare in the U.S. as almost all cases get some form of treatment as a child. It is becoming more prevalent with the growing number of immigrants who did not have access to plastic surgery care in their country of origin. But regardless of the nationality of the adult, the tilt in ear reconstruction favors the use of a synthetic framework method as it avoids a rib graft scar and the unpredictability of how well adult rib cartilage can be shaped.

Case Study: This 40 year-old female presented with an isolated type 2 right microtia that had never been treated. The remainder of her face was unaffected. A template was made of the opposite left ear and transferred to the affected right side for optimal angulation and height of the ear reconstruction.

Under general anesthesia a vertical incision above the ear was made up into the temporal region. From this incisional access a temporals fascial flap (TPF) was raised from the temporal line downward maintaining the superficial temporal vessels as its vascular pedicle. A Medpor ear framework was used and placed into a subcutaneous pocket that contained the ear remnants on its outer surface.

Once the synthetic framework was placed, the temporalis fascial flap was brought down over and into the subcutaneous pocket to cover as much of the implant as possible. The superior part of the flap and implant was covered with a full-thickness skin graft. In a second stage procedure three months later, the residual elements on the skin were removed.

When seen six months after the original framework and flap reconstruction, and three months after the remnant excisions, the shape of the ear reconstruction had good detail. The skin grafted area looked much whiter than the surrounding natural ear skin as would be expected.

In adult microtia reconstruction, an implant and autologous soft tissue coverage approach is preferred. It produces the best looking result due to the implant’s shape and often can be done in just one stage with simultaneous flap and skin graft outer coverage.

Highlights:

1) Adult microtia reconstruction is very uncommon in the U.S.

2) Adult ear reconstruction usually consists of a synthetic framework covered with a temporalis fascial flap and skin graft.

3) In adult females the temporal scar is less relevant than it is in many adult males for the peddled flap harvest.

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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