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Archive for the ‘chin augmentation’ Category

OR Snapshots – Medpor Chin Implant Removal

Saturday, 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.

medpor-chin-implant-removal-and-sliding-genioplasty-replacement-intraop-dr-barry-eppley-indianapolisIn 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

Indianapolis, Indiana

Case Study – Chin Implant after Sliding Genioplasty

Saturday, August 6th, 2016

 

Background: The sliding genioplasty is a well known chin augmentation procedure that is often viewed as a substitute for a chin implant. While this is certainly true in some patients, for other patients it is a better alternative as both an autologous operation and because it can offer some dimensional chin changes that an implant has historically not been able to do.

One dimensional limitation of this bony genioplasty operation is that the amount of horizontal augmentation obtainable is controlled by the thickness of the bone. To ensure bony healing as well as survival of the downfractured chin segment, bone contact must be maintained. This means that the maximal amount of horizontal bone movement is that the back cortex of the mobilized chin segment must stay in contact with the front cortex of the intact chin bone above it.

Because of this anatomic limitation not every sliding genioplasty can achieve ideal chin projection. This leaves the role of a chin implant to achieve an even better chin augmentation result.

Chin Deficiency after Sliding GenioplastyCase Study: This 25 year-old female had previously undergone a sagittal split mandibular advancement with a sliding genioplasty. Even with these two combined lower jaw movements, her chin projection remained aesthetically deficient.

Chin Implant after Sliding Genioplasty intraop Dr Barry Eppley IndianapolisUnder general anesthesia an intraoral approach was used to access her chin. A extended medium chin implant was placed below the existing metal plate from her prior sliding genioplasty. The implant was positioned lower on the chin bone to help create some vertical lengthening as well. (8mms forward and 3mm down) The implant was secured in its position with two 1.6mm screws at the superior aspect of the implant.

There is no reason that an implant can not be placed on top of a prior sliding genioplasty. This would be the simplest way to improve a prior bony chin augmentation procedure. With the many styles of chin implants now available many alloplastic options exist to change the shape of the prior remodeled chin bone.

Highlights:

1) A sliding genioplasty does not always create the ideal horizontal position of the chin particularly in significant lower jaw deficiences.

2) A chin implant can be a secondary addition to a prior sliding genioplasty.

3) The extended wings of a chin implant can help camouflage any bony irregularities along the jawline from the prior sliding genioplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Chin Implants and Injectable Fillers

Sunday, May 29th, 2016

 

Chin Implant Augmentation Indianapolis Dr Barry EppleyChin augmentation is a common aesthetic facial reshaping procedure that is second only to rhinoplasty. It has been traditionally performed by the placement of a preformed implant. While many different chin implant styles have been used over the years, the basic concept of an alloplastic chin augmentation is the same.

The emergence of injectable methods for facial augmentation using a variety of injectable fillers and fat has now become an accepted treatment approach for chin augmentation. While no injectable material offers an assured and permanent outcome as that of an implant for chin augmentation, it does provide an opportunity for patients to non-surgically ‘wear’ the result for awhile to determine if it suits them.

An interesting but relevant issue when using injectable fillers for chin augmentation is how do they compare volumetrically. To create an injectable chin augmentation effect, what volume of injectable filler is needed to compare to what a chin implant does? It is not a fair comparison if one is ‘testing’ an injectable filler and the volume injected does not equal what that of the effect that a chin implant does.

Volume Displacement of Facial Implants Dr Barry Eppley Indianapolisextended-anatomical-chin-implantComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and all chin implants do) Using the most commonly used extended anatomic chin implants (Implantech) of small, medium, large and extra large, their weights in grams and volume displacement were as follows:

Small Chin Implant        2.1 grams     1.3cc

Medium Chin Implant   2.7 grams      1.7cc

Large Chin Implant      3.4 grams     2.2cc

X Large Chin Implant  4.0 grams     2.7cc

The volume displacement of all injectable fillers is on the syringe so the comparison to chin implants is straightforward. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be less than even a small chin implant. A small anatomic chin implant more favorably compares to 1.5cc of Radiesse. Larger chin augmentation effects requires up to 3ccs of injectable filler regardless of the type.

There are other variables that affect how any of these materials create an external facial augmentation effect. The most significant would be how well does the material push on the overlying soft tissues or push off of the bone to create their effect. This is known as G Prime Force or their elastic modulus. It is quite clear that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) Therefore it is probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to that of chin implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Vertical Lengthening Chin Implant

Sunday, January 24th, 2016

 

Chin augmentation is the most historic but still the most commonly performed facial augmentation procedure. While many other types of facial implants have been developed, increasing projection of a deficient lower face is still the most potentially dramatic facial augmentation change of them all.

Chin implants have evolved considerably over the past few decades with numerous new styles. The fundamental concept of these style changes has been to create a more natural chin augmentation look or augment different regions of the chin area. But the one constant of all the chin implant styles is that they create a straight horizontal dimensional increase. This is so because all of the implant remains on the front edge of the chin bone.

But some chin deficient patients have more than just a horizontal bone deficiency. Certain short chins are also vertically deficient as well. Historically the only surgical method to substantially increase chin height was an opening wedge sliding genioplasty.  While effective some patients would prefer to avoid a bone cutting surgery.

While it is true that a standard chin implant can be placed very low on the  bone(on its ledge so to speak), this is not how the implant is designed or made to be used. This makes it potentially unstable to sit on the lower end of the bone and, even in doing so, produces a a very limited vertical lengthening effect.

Vertical Lengthening Chin Implant vs Standard Chin Implant Dr Barry Eppley IndianapolisTo address the combined horizontal and vertically lacking chin with an implant, the vertical lengthening chin implant (Implantech) has been developed. What is unique about this chin implant style is that the projection of the implant goes down from the chin at 45 degrees. This creates a combined horizontal and vertical increase. The implant actually sits on the ledge of the chin by design and thus it is more stable. To ensure optimal stability and positioning, a single 2.0mm screw can be placed through the implant to the bone when done from a submental incision. When done intraorally, a 1.5mm screw can be placed through the top edge of the implant to prevent any risk of upward migration. (which actually should be done with all chin implants placed intraorally)

Vertical Lengthening Chin Implant result 1 Dr Barry Eppley IndianapolisVertical Lengthening Chin Implant result 2 Dr Barry Eppley IndianapolisProper patient selection for the vertical lengthening chin implant is critical. It should only be used in patients with a significant vertical deficiency of the chin that also has a horizontal shortness as well. Most of these patients with have an almost 45 degree backward slant between the lower lip and chin. In general, the shorter the horizontal chin deficiency the more likely there will chin height shortness as well. Because it is an implant the width of the chin will also get bigger as the chin gets longer with greater horizontal projection. (a key aesthetic consideration)

Vertical Lengthening Chin Implant result 3 Dr Barry Eppley IndianapolisIn some men with slight or even no real vertical deficiencies, the addition of chin height will create a stronger or more masculine lower facial appearance. While this may be effective for some men, this is not a good strategy for women.

Vertical Lengthening Chin Implant sizes Dr Barry Eppley IndianapolisDifferent sizes (angulations) of the vertical lengthening chin implant are available which can increase the vertical up to 7ms while increasing the horizontal up to 12mms. Such chin augmentation changes may allow some patients to avoid an osteotomy of the chin.

The vertical lengthening chin implant is truly the first 3D chin implant ever made as it increases all three chin dimensions.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Extended Chin Implant

Tuesday, October 6th, 2015

Background: Chin augmentation is the commonly performed facial bone augmentation site. Chin implants have been around for almost fifty years in a preformed fashion. A large number of different chin implant styles and sizes now exist that seemingly can treat just about every type of aesthetic chin deformity.

Chin Implant with lateral wings compared to a central button chin implant Dr Barry Eppley IndianapolisThe single greatest change/advance in chin implants over the past decade has been the concept of adding wings or lateral extensions. This makes sense for most chin augmentations to avoid a ‘bump-like’ appearance on the front edge of the chin and to have the implant flow more smoothly around the bony curvature of the chin. These wings can extend back onto the parasymphyseal area and front portion of the body of the mandible. The purpose of chin implant wings is not to add volume but to create a smooth transition between the implant and the jawline.

But not all aesthetic chin deformities truly stop at the front edge of the mandible. While the jaw behind the chin may not be especially short, the lower edge of the jawline is often not well defined. Adding volume or definition alone the jawline with a chin augmentation can be of benefit to some patients.

Case Study: This 50 year old female had numerous surgeries in the past to treat a medical problem that left her with multiple problems of the lip, chin and jawline. As part of her treatment strategy, an extended chin implant was planned to build up her chin as well as back along the jawline. The goal was to create a volumetric effect along the entire jawline.

Extended Chin Implant design and placement Dr Barry Eppley IndianapolisUnder general anesthesia she had multiple procedures done (e.g., fat grafting, lip resuspension) as well as an extended chin implant through an existing submental incision.

Custom Extended Chin Implant result oblique view Dr Barry Eppley IndianapolisCustom Extended Chin Implant result front view Dr Barry Eppley IndianapolisAt six months after surgery, it can be seen that the effect of the extended chin implant was beyond that of just horizontal chin augmentation. The entire jawline behind the chin just short of the jaw angles had augmentation to make it slightly wider and more defined.

The extended chin implant concept is a much longer extension than that of the traditional winged chin implant. It can provide true increased jawline definition behind the chin since it is designed to do so. Such an extended chin implant can have numerous applications to other patients who need/want jawline definition but not necessarily stronger jaw angles.

Highlights:

1) Augmentation of the jawline can be done beyond that of the chin using a specially designed preformed implant.

2) Creating a more defined jawline extending backwards from the chin can be done with an extended chin implant.

3) The wings of all preformed chin implant do not extend much beyond the sides of the chin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Female Custom Chin Implant

Monday, September 7th, 2015

 

Background: Chin augmentation is the most commonly performed jawline enhancement procedure. It is also along with rhinoplasty the most common facial bone reshaping operation. Placing an implant over the end of the chin bone is conceptually simple. But the wide variety of chin implant styles and sizes demonstrates that the aesthetics of chin augmentation is not so simple.

Female Chin Augmentation Surgery Dr Barry EppleyWhile there are no gender specific chin implants made, it is clear that there are differences in the male and female chin. The ideal male chin is known to be stronger (greater horizontal projection), wider and have a more angular or square shape. Conversely the ideal female chin is more narrow, triangular in shape and can tolerate slightly less horizontal projection. The selection and use of chin implants is often done taking these aesthetic concepts into consideration. Unfortunately often they are not and this can create one reason for dissatisfaction from chin implant surgery.

For many female improvement in their chin shape comes best from an overall ‘cupping effect’ on the chin. The chin may need some modest horizontal augmentation but may need some vertical increase as well. The implant then needs to blend into the sides of the chin to maintain a more triangular shape. Such an implant shape does not come in any standard form and must be custom made.

Custom Chin Implant design front view Dr Barry Eppley IndianapolisCustom Chin Implant design side view Dr Barry Eppley IndianapolisCase Study: This 46 year old female wanted her chin shape improved but did not desire just a simple horizontal advancement. She wanted a modest change but one that had more of an overall chin shape augmentation but still keep a feminine look. She also had bony chin asymmetry as evidenced by a vertically longer genial tubercle on the right side. From her 3D CT scan a custom chin implant was designed and made. The implant design corrected her asymmetry but also keep a more triangular shape.

Custom Chin Implant placement intraop Dr Barry Eppley IndianapolisCustom Chin Implant design top view Dr Barry Eppley IndianapolisUnder general anesthesia the custom chin implant was placed through a small 2 cm incision in the submental skin crease. The implant as expected (and should) fit perfectly over the chin bone. It was secured into placed with a single 1.5mm titanium screw

Chin augmentation can be accomplished in the majority of cases by using preformed standard implant styles and sizes. From one manufacturer alone (Implantech) there are seven different styles of implants with three or four different sizes. For most people this assortment will be more than adequate. But not every chin augmentation patient fits the normal implant options and this is the role that a custom chin implant serves.

A custom chin implant is often thought of as being for extreme cases where the amounts of chin dimensional changes exceeds what the standard implant can do. While this is certainly one role that a custom chin implant can do well, they can also be used for more modest chin shape changes that are not served by performed standard styles.

Highlights:

1) Chin augmentation is most commonly performed by a variety of standard styles and sizes of implants.

2) Standard styles of chin implants can not add consistent vertical length and can not create a cupping effect over the chin bone.

3) A custom chin implant can be made in any shape and can be a better option for certain types of female chin deficiencies.

Dr. Barry Eppley

Indianapolis, Indiana

Chin Implant Imprinting

Wednesday, August 26th, 2015

 

The use of a chin implant for an increase in lower facial projection is often combined with other procedures (e.g., rhinoplasty) as well as done as an isolated chin augmentation. It has a long history of use in aesthetic facial surgery dating back over fifty years and nearly every available biomaterial has been tried as some form of a chin implant. But the use of silicone chin implants today constitutes the majority of chin augmentation devices used.

One phenomenon of placing a silicone chin implant (it also occurs with other biomaterials as well) is that of ‘chin implant erosion’. This is an erroneous term that implies that a chin implant is actively eating into or destroying the chin bone underneath it. (aka an active inflammatory process occurring as a a result of a bone reaction in response to a leaking of silicone molecules from the implant) That perception and propagated term is far from what actually occurs.

Chin Implant Imprinting 3 Dr Barry Eppley IndianapolisThe chin is a unique facial area for augmentation because it is a projecting bony structure with tight tissue attachments that wrap around it. Thus when an implant is placed between the chin bone and the overlying soft tissues it will exert some forces (pressure) on the underlying and overlying soft tissues. The body will relieve this pressure with passive adaptation to it. Since the chin implant can not change due to its synthetic inert structure, the surrounding tissue must. As a result, the chin implant will often (although not always) settle a millimeter or two into the bone as a form of pressure relief. This can be seen in great detail as the serial number, size indicator or any grooves or markings on the implant can be seen on the bone surface as the implant is removed.

Chin Implant Imprinting Dr Barry Eppley IndianapolisThis passive bony remodeling phenomenon to a chin implant is benign and self-limiting. It has little to no impact on the external aesthetic chin augmentation result and does not affect the quality of the underlying bone. Because most chin implants are placed in the subperiosteal plane this settling will also allow some bony growth to often extend up along the sides of the implant. Such bony overgrowth can be seen clearly intraoperatively as well as on CT scans. This bony overgrowth further implies that the implant is not causing a destructive bony process.

There are very rare cases where chin implant settling has placed the mandibular incisor tooth roots at risk or has caused some dental sensitivity. This is a direct result of a chin implant being placed far too high over the much thinner cortical bone near the tooth roots. As a result, passive implant settling may occur deeper into the bone and appear very close radiographically to the tooth roots. This is the direct result of an incorrect chin implant placement.

It is time to eliminate the term ‘chin implant erosion’ due to its biologic inaccuracy and replace it with a term that correctly identifies it with the passive bony remodeling process that it is. The better descriptor would be ‘chin implant imprinting’.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Geniopasty with Indwelling Chin Implant

Sunday, May 3rd, 2015

 

Background: Horizontal chin augmentation can be done using either a synthetic chin implant or a sliding genioplasty. There are advantages and disadvantages with either approach and they must be considered in an individual patient basis. The decision in any patient ultimately depends on their perception of an alloplastic vs. an autogenous approach, the risks of the procedure and its recovery and what other dimensional changes of the chin that are needed beyond just that of the horizontal change.

But the use of a chin implant does not always produce the desired amount of chin augmentation change that every patient desires. This may be due to inadequate implant selection, the chin implant settling into the bone thus losing some horizontal projection, chin implant malposition or an accommodation to the initial chin augmentation result.

When further improvement is desired after an initial chin implant augmentation, the options are either a larger implant or to convert it to a sliding genioplasty method. A larger implant is usually done as this is the simplest revisional approach provided that a new implant can create the desired horizontal change. When a larger chin implant offers but a modest additional augmentation (e.g., 5mms or less) the the sliding genioplasty option becomes a consideration. It would be either that or have a custom chin/jaw implant made.

Chin Implant Settling (Erosion) Dr Barry Eppley IndianapolisCase Study: This 26 year-old male wanted additional chin augmentation after having a prior chin implant placed several years previously. He always felt that is lower jaw was smaller. His original chin implant provided 7mms of horizontal projection but it could be seen that it had settled into the bone a few millimeters. He opted for a sliding genioplasty as he felt that would more reliably give him long-term augmentation.

Sliding Genioplasty with Chin Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was used to access the chin. The chin implant was easily identified and it was nestled nicely into the bone. A horizontal osteotomy cut was made above it from side to side and the bone downfractured. The chin segment was then advanced 12mms and stabilized with a step plate and screws. The chin implant was never moved from its original position during the procedure.

Sliding Genioplasty with Chin Implant result Dr Barry Eppley IndianapolisSliding Genioplasty with Chin Implant 3D CT scan Dr Barry Eppley IndianapolisA sliding genioplasty can be successfully done with an indwelling chin implant. It can be argued that this is a good technique to take advantage of some of the prior procedure (and investment) and gain additional horizontal augmentation. Whatever implant settling has occurred into the bone has already reached its peak and no further inward change would be anticipated.

Case Highlights:

1) An unsuccessful chin implant result can be improved by a sliding genioplasty.

2) It is not always necessary to remove an existing chin implant when doing a sliding genioplasty.

3) A sliding genioplasty can be performed by making the osteotomy cut above the chin implant and moving both forward simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty for Lower Facial Elongation

Tuesday, April 14th, 2015

 

Background: A sliding genioplasty is a well known and historic procedure for changing the shape of the chin. It was originally described in the 1940s but has evolved considerably due to the use of rigid fixation using plates and screws. While once clever osteotomy designs and wire fixation methods were used for stabilization of the bone segments, which limits how much the chin position could be changed, plate and screw fixation now makes virtually any bony chin change possible.

Sliding Genioplasty Indianapolis Dr EppleyFor chin augmentation, the chin implant is often compared to the sliding genioplasty as creating similar effects. But the reality is that this is only partially true and they are only comparable when it comes to pure horizontal movements as seen in the profile view. Vertical and width (narrowing) changes can not be done with an implant. (although newer vertical lengthening chin implants have recently become available)

The real benefits for a sliding genioplasty are when vertical elongation of the chin is needed and when the amount of chin advancement desired exceeds that of which standard implants can achieve. This would be particularly useful in women who can aesthetically tolerate a more narrow chin as it comes both forward and down. The other benefit for a sliding genioplasty in these more substantial chin changes is that it ‘carries’ the soft tissue of the chin pad with it and does not create a devascularizing effect due to maintaining most of the soft tissue attachments (and resultant perfusion) to the bone.

Case Study: This 26 year-old female had a short chin in both horizontal and vertical dimensions. Her lower facial height was disproportionate to the rest of her face. As a result, she appeared to have a full neck/double chin.  She knew she wanted her chin augmented but was just not sure how it should be done.

Sliding Genioplasty result side viewSliding Geniop[lasty result oblique viewUnder general anesthesia, she underwent an intraoral sliding genioplasty. A low horizontal bone cut was done and the chin was advanced 16mm forward and 8mms downward. This was the maximum amount of chin bone movement that could be done while still maintaining some bone contact between the segments. Rigid fixation was achieved by a titanium step plate and screws. The bone gap (step between the upper and lower bone segments was filled with demineralized bone particles. The mentalis muscle was resuspended at closure.

Sliding Genioplasty result front viewThe vertically opening sliding genioplasty can help make the lower face more proportionate by making bringing it forward and down. This will make the jawline have more of a V-shape and will also help get rid of a double chin problem due to lack of bony projection.

Case Highlights:

1) A sliding genioplasty is historically the only chin procedure that can provide both horizontal and vertical elongation of the chin. (custom made implants can now do that also)

2) A vertically opening sliding genioplasty with horizontal advancement will make the chin more narrow as a result of these bony movements.

3) Unless the bony chin movements are extreme, bone grafting of the interpositional gap between the chin segments is not necessary. Even when needed demineralized bone substitutes can be successfully used.

Dr. Barry Eppley

Indianapolis, Indiana

Minimal Incision Chin Augmentation

Thursday, March 12th, 2015

 

Chin Implant Styles Dr Barry Eppley IndianapolisChin augmentation using synthetic materials is both the most historic facial implant procedure and still the most commonly done. This is evidenced in that chin implants have the largest number of styles and sizes commercially available of any facial implant manufactured today. Chin implants are inserted by incisions either from the inside of the mouth mucosa or through the skin under the chin. There are advocates for either approach but successful chin augmentation results can be obtained either way with good attention to their unique technical details.

The placement of chin implants is most commonly done from a submental skin incision. It has the advantages of more limited disruption of the mentalis muscle of the chin, less risk of lower lip numbness and a more assured and sustained placement of the implant on the lowest portion of the chin bone. (where it belongs for its maximal effect) Understandably some patients are concerned about the final appearance of the submental scar. This concern is most significant in patients of intermediate skin pigments.

I have seen many submental chin implant scars and there are often much larger (longer) than they need to be. The use of silicone chin implants, even the longer anatomic or winged ones, allows for the implant to be inserted in a folded fashion, one half at a time. This enables a remarkably small incision to be used despite the length of the chin implant.

Small Chin Implant Incision Dr Barry Eppley IndianapolisThe key is to develop the subperiosteal tunnels along the sides of the chin bone in largely a blinded fashion. Once the incision is made down to the bone, small elevators are used to  made the subperiosteal tunnels along the inferior border of the mandible. It is important to make these tunnels longer than the wings of the implant on each side. By so doing half of the implant can be inserted and slide past its midline to one side. This will allow the opposite wing to be folded and inserted easily and then slide back to the midline.

Small Incision for Chin Implant Dr Barry Eppley IndianapolisOnce the implant is in the tunnels it can be slide back into the midline and secured by whatever fixation method one desires. (in this case of a vertical lengthening chin implant a 1.5mm screw was used)

Minimal incision chin augmentation can be very effectively done through a submental skin incision using preformed silicone implants.

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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