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Archive for the ‘Clinic Snapshots’ Category

Clinic Snapshots – Cupid’s Bow Reduction result

Tuesday, September 5th, 2017

 

The dominant feature of either upper or lower lip is that of the cupid’s bow. It is really the only non-linear feature of the lips. The resemblance of the double curve of the upper lip to a bow laying on its side is obvious. While peaks of the bow could resemble any bow, it presumably refers to the Roman god of love, Cupid, because of the potentially sensuous nature of the lips. They develop as a result of the fusion of the prolabial process and the lateral lip elements in utero.

The strength of the shape of the Cupid’s bow varies greatly amongst different people and is related to overall lip size. Larger lips are more prone to have a prominent cupid’s bow while thin lips often had little evidence of one. Great effort is made by lip injection techniques to make a more prominent bow and several surgical procedures exist as well to help create it. (lip lift, lip advancement)

But there are some women who want to have a less prominent cupid’s bow and an upper lip with a smooth vermilion-cutaneous across its arc from mouth corner to mouth corner. A cupid’s bow reduction procedure can be done by excising a small elliptical segment of skin between the bow peaks and the vermilion advanced upward. While very straightforward to do, the effects of gravity and tissue contraction do potentially work against its effectiveness. Fortunately the vermilion of the lips are flexible and do permit more stretch than of the surrounding skin.

The biggest concern, beyond effectiveness, is whether there will be adverse scarring from a cupid’s bow reduction procedure. As this case illustrates the scarring is very minimal and barely if at all perceptible. Should there be visible scarring it is also a procedure which is easily revised since it is done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – The Precision of the Upper Blepharoplasty

Friday, July 21st, 2017

 

Aging of the eyes is often the first sign of facial aging. Its develops initially because the thin skin of the eyelids and their frequent movement creates excessive excessive and loss skin. The upper eyelid often suffers the worst because it actually is more active than the lower eyelid with a greater excursion of movement. Skin folds or hooding develops eventually in everyone and no one is immune to this occurrence.

For this reason upper blepharoplasty or an eyelid lift is one of the most common of all facial plastic surgeries. In this procedure the excessive upper eyelid skin is removed with or without a strip of orbicularius muscle. In some cases bulging orbital fat may also be removed but the cornerstone of the procedure’s success lies in the skin removal. This is unlike the lower eyelid where considerations of fat removal, management of tear troughs and laxity of the lower eyelids all play a significant role in the aesthetic outcome of the procedure.

While the tissue removal in upper blepharoplasty seems ‘simple’ it is still a precise operation that must be marked out carefully before surgery. The final location of the incisional closure is critical as the scar line needs to end up in a natural skin crease that is hidden when the eye is opened. It can not end up too high or too low and should be retracted back into the depth of the supratarsal crease as the eye opens for invisibility. The symmetry of its location in each eyelid must also be equally matched from each lid’s lash line.

There can be a debate about the merits of removing any orbicularis muscle with the upper eyelid skin removal. In doing so the depth of the supratarsal crease may be deepened for better eyelid crease definition and without any compromise of upper eyelid closure function.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Retrotragal Facelift Incision

Tuesday, June 27th, 2017

 

The facelift is one of the most common of all facial rejuvenation procedures. While there area a myriad of methods to perform it with various technical maneuvers that can seem bewildering to the patient, the most basic part of it remains the incision around the ears. While perhaps not the most technically challenging part of the operation it is certainly the most visible.

No matter how well the ‘inside’ of the facelift procedure is performed, poor incision placement, adverse scarring and hairline displacements/distortions will be an aesthetic detraction. These external markers can often be how a facelift is judged and is an understandable preoperative patient concern.

The basic facelift incision around the ear is often called preauricular or retrotragal. This refers to the incision on the front of the ear which represents a part of the total facelift and just a minor portion of its total incisional length in most cases. But it is the most visible part of the incision and thus its aesthetic importance.

In almost all women and in many men the facelift incision will be placed in a retrotragal fashion. The incision will go inside or behind the cartilage bump (tragus) as it crosses this part of the ear. Otherwise the rest of the incision runs in the natural face-ear junction around the ear and up and back into the hairlines. Such placement hides part of the incision and helps break up scar tension on it due to its non-linear course. (this is an example of such an incision several weeks after surgery.

These type of facelift incision usually heals quite well and as discretely as one would hope. This is because it is not only hidden but because it is closed with no tension after the excess skin is removed.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Mandibular Inferior Border Shave

Friday, March 17th, 2017

 

Facial asymmetry often involves the lower jaw. Since the lower jaw defines the border of the face to the neck, any differences between the two sides of the face can be clearly seen.  It is usually not difficult to determine which is the normal side and which is the affected side although this is ultimately determined by patient preference.

In cases of facial asymmetry caused by either excessive lengthening or a more inferiorly positioned bony half of the face, the inferior border of the lower jaw is too long. This is most clearly seen in a simple panorex x-ray where the entire lower jaw is laid out in a flat 2D fashion. It is also clearly seen in a 3D CT scan with a side view showing the different heights of the lower border of the mandible.

Removal of the lower inferior border of the mandible is done by a saw cut based on measured differences between the two sides. This usually needs to run from the chin back to the jaw angle. This bony cut is most easily done from a submental incision where it becomes a straight line with the best visualization. While this can be done from an intraoral approach, this makes it much more difficult and has a greater risk of injury to the inferior alveolar nerve.

Mandibular Inferior Border Shave Dr Barry Eppley IndianapolisThe straightness of the bony cut (mandibular inferior border shave) from a submental incision can be seen in this before and after x-ray assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Rib Removal Waistline Narrowing

Saturday, March 4th, 2017

 

Rib removal surgery can be an effective procedure for anatomic waistline reduction in properly selected patients. Such patients typically include the already thin female who is seeking an ‘extreme’ waistline reduction as well as the male to female transgender patient who is trying to achieve a more feminine waistline shape.

Rib removal is effective in either type patient because it removes an anatomic bony obstruction that then allows the soft tissues to collapse inward. It is only necessary to remove the outer half of the ribs that extend laterally beyond the outer border of the erector spinae muscle. The inner half of the rib remains intact as its medial end is still attached to the vertebral facets.

Rib Removal for Waistline Narrowing Dr Barry Eppley IndianapolisThe procedure is done through  incisions of about 4 cms in length  that are obliquely placed in a skin crease that is made evident by turning at the waist. While the resolution of swelling and waist training can create an even greater change, the increased narrowing of the anatomic waistline can be appreciated even at one week after surgery.

Rib removal is a perfectly safe surgery contrary to the perception of many patients and even most surgeons. Since only a portion of the rib is removed and there is no real loss of structural support, it can be performed for purely aesthetic purposes.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Rib Removal Waistline Narrowing

Thursday, February 9th, 2017

 

Rib removal is an aesthetic body contouring procedure that has an impact on narrowing the anatomic waistline. It is most commonly performed in my experience on already lean women that are trying to achieve an ultra narrow waistline or on male to female transgender patients to get some semblence of a waistline shape. While historically portrayed as an urban myth, rib removal surgery is very real and effective in the properly selected patient.

Rib Removal results front view Dr Barry Eppley IndianapolisTo create a waistline narrowing effect, the free floating (11th and 12th) ribs are shortened in their length. The concept of rib removal does not mean the entire ribs are removed back to their vertebral facets. Rather they are shortened back to the lateral border of the erector spinae muscle. This removes some support from the overlying soft tissues but does so without risk to any internal organs. This collapse inward of the soft tissues creates the waistline narrowing effect.

The debate in each patient is whether a portion of rib #10 should also be removed in addition to ribs #11 and #12. Rib #10 is not a free floater and has a more horizontal orientation. Its removal has less of an effect on the waistline than the lower two but a portion is often removed as well.

Rib Removal result back view. Dr Barry Eppley IndianapolisTraditional rib removal by chest surgeons is done through long incisions. But that is not acceptable in the cosmetic patient. Aesthetic rib removal is done through a 4 to 4.5 cm long incision placed in an oblique skin fold seen when the patient turns at the waist. This produces a far more acceptable incisional tradeoff. This patient picture shows the result seen just two days after rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Posterior Zygomatic Arch Osteotomy Incision

Thursday, January 26th, 2017

 

Cheekbone reduction surgery requires an understanding of the complete bony anatomy of the zygomatic bone. When most people think of the cheekbone ti is perceived as one solid block of bone just underneath the eye. While this area is a major part of the cheekbone, it overlooks the posterior extension of the cheekbone known as the zygomatic arch.

The zygomatic arch connects the main body of the cheekbone (zygoma) to the temporal bone above the ear. It is a thin bridge of bone between these two areas because underneath it passes the large temporalis muscle on its ways to attach to the lower jaw. The zygomatic arch is almost always bowed outward or has a convex shape. This gives width to the side of the midface.

In cheekbone reduction it is rarely a matter of shaving down the bone. Rather the cheekbone is cut and moved inward, this is what make the side of the face more narrow. The bone cuts are done in the front through the main body of the zygoma from an intraoral incision. Conversely the back cut is done where the zygomatic arch meets the temporal bone through an external incision.

Posterior Zygomatic ASrch Incision Healing Dr Barry Eppley IndianapolisThe external incision for the zygomatic arch osteotomy is done through the sideburn hair. It is usually about 1 cm in length and is placed at the junction of the sideburn hair and skin just in front of the ear. Because it is an external incision patients understandably are concerned about how it heals an whether it heals in an inconspicuous manner. Here is a picture of a patient with a posterior zygomatic arch osteotomy incision that was done just over one year ago.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Good Riddance Abdominal Panniculectomy

Thursday, December 29th, 2016

Cosmetic surgery of the abdomen and waistline is one the most common body contouring surgeries for either women or men. Women in particular are inclined to undergo these surgeries as they are victims of a lot of body changes from pregnancy and/or weight gain/loss. Liposuction and tummy tucks make up the bulk of these surgeries as they fall into the norm of the type of body changes that need to be treated.

But amongst tummy tuck surgeries there is a ‘supersize’ version due to the magnitude of the tissues that need to be removed. This enlarged version of a tummy tuck is known as an abdominal panniculectomy. The abdominal panniculectomy differs from all forms of a  tummy tuck as it removes a large segment of overhanging tissues known as a panniculus. Also known as an abdominal apron, this is a large amount of abdominal tissue that overhangs the waistline down on the thighs. In large abdominal pannuses it can even hang down as low as the knees!

abdominal-panniculectomy-indianapolis-dr-barry-eppleyThe abdominal pannus and its weight causes a constellation of problems for the person from chronic skin infections and moisture underneath it to the strain of its weight on the back and knees. This is not to mention the limitations imposed on clothing options to hold it in or try and hide it. It is no surprise then that when the day comes for their abdominal panniculectomy surgery there are no regrets in losing a bit of oneself!

While an abdominal panniculectomy may not be as eloquent as an operation as many smaller tummy tucks, patients are usually even more grateful.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Pectoral Implants with Abdominal Etching

Monday, December 26th, 2016

 

The principal method to augment the male chest is with the use of pectoral implants. Like in the female breast, the placement of a pectoral implant creates an immediate chest enlargement. The fundamental difference between a female and make chest implant is that one is a fluid-filled device while the other one is solid. The male pectoral implant is designed to completely replicate muscle and therefore can be more firm. Conversely a breast implant is designed create a breast mound that is softer and more supple.

Pectoral implants come in a variety of sizes with several shape choices. With standard volumes sizes now up to over 600ccs significant chest enhancement cab be achieved in just about any male regardless of their size. As a solid implant they have a low durometer which not only makes the feel much like muscle but also allows them to be introduced through a high axillary incision as well.

pectoral-implants-and-abdominal-etching-result-front-view-dr-barry-eppley-indianapolisA good complement for the male chest enhancement patient is that of abdominal liposuction or abdominal etching. Since they can both be performed in the supine position it is a good opportunity for a ‘male maleover’ with combined chest and abdominal reshaping.

The creation of a ‘six-pack’ is a form of liposculpture using focused fat removal along specific lines. Designed to replicate the appearance of the abdominal inscriptions, etching mimics those lines by creating a dermal-fascial adhesion. Abdominal etching works best in the thin patient. But it can be done at the same time as overall liposuction in men with thicker subcutaneous abdominal wall layers albeit with not the same abdominal etch line definition as in thinner men.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Jaw Angle Augmentation Fillers vs Implant

Monday, December 26th, 2016

 

Augmentation of the facial skeleton has historically been done through the placement of preformed implants. The past decade has seen the emergence of a variety of injectable materials to create soft tissue volume augmentation. These have included a large number of synthetic fillers as well as autologous fat. As their use has become more common and pervasive throughout aesthetic surgery, the injectable approach has been applied to every conceivable aesthetic facial need including augmentation of the bony cheeks, chin and jaw angles.

An injectable filler can be used for jaw angle augmentation. It does not usually produce the same result as a well selected jaw angle implant as it can not create angularity and sharper definition with the push of a soft material like fillers or fat. Thus injectable fillers for jaw angle augmentation is often done as a test or trial or are sometimes performed as a convenient opportunity at the time of other facial surgery using fat injections.

jaw-angle-implants-vs-injectable-fillers-dr-barry-eppley-indianapolisBut beyond that of a trial, the use of injectable fillers as a long-term method of jaw angle augmentation is compromised by economic issues. When one compares the volume of an injectable filler to an actual jaw angle implant (in this picture 1.5cc of Radiesse to a medium vertical lengthening jaw angle implant) the tremendous discrepancy in its volume/size can be seen. By comparing weights alone it can be seen that it would take more than 5cc to 7cc of a filler to match the volume created by an implant.

Because of their long-term cost issues, injectable fillers are a short-term approach to jaw angle augmentation. This is not only because they are not permanent but the sheer cost of trying to replicate an initial jaw angle implant effect.

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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