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Dr. Barry Eppley

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Archive for the ‘earlobe reconstruction’ Category

OR Snapshots – Total Ear Reconstruction with TPF Flap

Monday, December 26th, 2016


Loss of the ear through either traumatic amputation or from tumor resection poses major reconstructive challenges. There is not only the replacement of the supporting ear cartilage that is responsible for making the ear look like an ear. But there is also the replacement of the lost skin that covers the underlying ear framework. The latter is more challenging then the former.

The choice of an ear framework replacement always comes down to either that of an intraoperatively assembled rib graft construct or a preformed synthetic Medpor framework. Each method has their own distinct advantages or disadvantages. In the older patient where the rib cartilages are more calcified, a synthetic ear framework creates a more reliable ear shape.

But the real challenge in recreating a vascularized soft tissue cover over whatever framework is chosen. Without a living skin cover that has some thickness, the choice of ear framework reconstruction is irrelevant. Any exposure of an ear framework, even that of rib cartilage, will result in infection and loss of it.

temporoparietal-flap-in-ear-reconstruction-dr-barry-eppley-indianapolisIn total ear reconstruction the only choice for a well vascularized soft tissue cover is a pedicled temporoparietal fascial flap. (TPF flap)  This is a well known pedicled flap that is an extension of the subcutaneous musculoaponeurotic system (SMAS) inferiorly and the galea aponeurotica superiorly.  It provides a thin sheet of vascularized fascia based on the posterior branch of the superficial temporal artery and vein. It is raised high up into the temporal region and then turned down to cover the chosen ear framework material. The TPF flap is then covered by a thin skin graft to complete the soft tissue cover.

The TPF flap works because the incoming vascular supply comes in inferiorly allowing the flap to be safely turned down over the ear framework and it still remains alive.

Dr. Barry Eppley

Indianapolis, Indiana

Earlobe Attachment Surgery

Friday, October 14th, 2016


One of the features of an earlobe is in how they attach to the face. In some patients the earlobe curves upwards and attaches to the face in an inverted V shape. They are often referred to as unattached earlobes. In other patients the earlobe joins the face directly without any break in he attachment. This is often referred to as an attached earlobe. While earlobes are often described as either attached or unattached (free), the reality is that there are variations that commonly occur between these types.

Some people desire to change the way their earlobe attaches to the face. It is fairly easy surgically to take the unattached earlobe and make it attached. This is done by excising skin from the medial side of the earlobe as well as a similar strip of skin on the opposing facial side. the two are then sutured together. This union heals very well and does so in a virtually scarless manner.left-earlobe-attachment-surgery-result-dr-barry-eppley-indianapolis

right-earlobe-attachment-surgery-result-dr-barry-eppley-indianapolisConverting an attached earlobe to an unattached one poses a slightly different challenge. The skin attachment is released and the medial side of the earlobe is sewn up along its open margin. This changes the earlobe into a more rounded lower shape. But the facial side of the wound opening must also be closed and is done so in a linear fashion. This leaves behind a vertical scar in an unnatural location. Fortunately the wound closure heals fairly well in this location and can be partially obscured by the earlobe itself.

Changing the attachment of the earlobe to the face can be done under local anesthesia with negligible swelling and no real recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Repair of the Large Gauged Earlobe

Wednesday, October 29th, 2014


Gauging the earlobe through sequential expansion devices seems relatively new, but it is a custom in some cultures that dates back well into antiquity. It is the earliest form of tissue expansion and proves that even the smallest body structure can be modified by simple pressure. While it is a fashion statement for some today, usually in younger patients, it often is not a body alteration that is maintained over one’s lifetime. Thus it is not uncommon today to see a ‘looped‘ earlobe in which the owner would like to see a more normal earlobe restored.

For small gauged ears, removal of the gauge will allow much of the hole to shrink down. Given a few months the hole in the ear will usually end up as just a small slit in the middle of the earlobe. This is a well known phenomenon that occurs in tissue expansion when the device is removed. It can be remarkable how large of an earlobe hole can close down of given enough time. It will still require surgery to put the earlobe edges back together but the smaller the hole the easier and more natural it will look. But in very large gauged ears or if one is in need of a more rapid closure, a different earlobe reconstructive approach is needed.

In the October 2014 issue of the journal Plastic and Reconstructive Surgery Global Open issue, an article appeared entitled ‘Repair of Massive Earlobe Piercing and Plus (Gauging)’ In this short case report, the authors report a single patient in which one earlobe had a 3 cm hole secondary to gauging over a seven year period. The gauge was removed sic weeks prior to surgical repair. The earlobe was repaired and closed using a pedicled skin flap from the inferior rim. The anterior aspect of the expanded earlobe skin was removed the lower skin flap rotated up into the defect to recreate a smaller and shorter earlobe.

Gauged Earlobe Flap Repair Dr Barry Eppley IndianapolisWhile repairing a gauged/enlarged earlobe seems simple because there is an excess of skin, it is actually a bit trickier that it seems. Creating an earlobe that is not excessively long and actually looks like a natural earlobe can be challenging in very large gauged ears. This is because the anterior rim of expanded skin is very thin and often not useable. While in smaller gauged ears excising the low hanging loop of stretched earlobe skin and bringing together the front and back edges of the earlobe will work. (although it will result in an attached earlobe rather than one that has a separation between the earlobe and the side of the face) The excessively or massive expanded ear leaves the front edge of the earlobe unusable. This then requires using the expanded posterior earlobe as a tubed pedicled flap for the earlobe reconstruction as demonstrated in this paper.

Dr. Barry Eppley

Indianapolis, Indiana

Mini-Mommy Makeover Procedures

Sunday, May 19th, 2013

The concept of a Mommy Makeover plastic surgery procedure is about combining abdominal and breast reshaping in one operation. The breast and abdominal components are not new and include many well known procedures such as tummy tucks, breast implants, liposuction and breast lifts in whatever combination each individual women needs. While the effects of a Mommy Makeover can be dramatic, breast and abdominal procedures are major surgery with significant recovery as well.

But there are numerous other procedures of lesser magnitude that could also be lumped into the Mommy Makeover category and consist of a variety of ‘nips, tucks and sticks’ that create effects that mothers would also like. Here are some of the most noteworthy.

BOTOX  For reduction of those facial expression lines that come from the stress of balancing mother and wife roles, Botox injections are probably the most common injectable Mommy procedure.

Vi/PERFECT PEELS With only a few days of redness and flaking, these medium-depth facial peels are essentially painless to go through and provide a real boost to one’s complexion. A few of these a year will keep a mother’s skin radiant and glowing.

C-SECTION SCAR REVISION For those women that don’t need a tummy tuck and have a noticeable c-section scar with just a little pooch above it, widely cutting out the scar can produce a flatter upper pubic area. This scar revision can be combined with some lower abdominal liposuction for an additional and wider flattening effect.

UPPER LIP PLUMPING Some well placed Restylane or Juvederm injections into the upper lip has an instant youthful volumizing effect. This is particularly evident if the cupid’s bow and philtral columns are accentuated.

NIPPLE REDUCTION Breast feeding can elongate the nipple which can be a source of embarrassment and out of proportion to the size of the areola. Under local anesthesia, the nipple length can be reduced by half or more.

EARLOBE REPAIR Fixing stretched out ear ring holes or complete tears through the lobe can allow old or new ear rings to be comfortably worn again.

BELLY BUTTON REPAIR (Umbilicoplasty) Pregnancies can change an innie belly button to an outie due to a small hernia through the umbilical stalk attachment. Tucking the peritoneal fat back through the hole and reattaching the stalk of the belly button back down to the abdominal wall will recreate that an old inne look again.

EXILIS For those stubborn fat areas that just won’t go away despite some diet and exercise, this non-surgical fat treatment can easily fit into a busy mom’s schedule. It takes a series of treatments to see the effects but there is no downtime with 30 minute in-office treatment sessions.

These mini-Mommy Makeovers provide changes that do not require major surgery or recovery and can fit into anyone’s hectic schedule.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Earlobe Repair and Reconstruction

Sunday, March 17th, 2013


Repair of the earlobe is done for a range of conditions from a tear caused by an ear ring, stretching of the earlobe from gauging to traumatic injuries. The small size of the earlobe allows even complex repairs to be done under local anesthesia as an office procedure in most cases.

The after care instructions for earlobe repairs and reconstructions are as follows:

1. Earlobe repairs, whether a simple split repair or a more complete reconstruction, are associated with a minimal amount of pain in the first few days after surgery.  Usually narcotic pain medications are not needed and Tylenol or Ibuprofen are sufficient.

2.  There may be a small dressing (tape or bandaid) placed over the earlobes for the first 12 to 24 hours if the earlobe has significant reconstruction. Its purpose is to catch any oozing that may occur right after surgery. (usually there isn’t but as a precaution) It may be removed the next day. In smaller earlobe repairs there is no dressing used over the sutures.

3.  A light layer of antibiotic ointment needs to be applied to the sutures on the earlobes three times per day to keep them moisturized. This is done whether removeable or dissolveable sutures are used.

4. If permanent sutures are used, they will be removed by Dr. Eppley in 10 to 14 days after surgery.

5. You may shower, wash your face and shave (men) the next day. There is no harm is getting them wet with soap and water.

6. Do not pull on your earlobes or wear clip-on ear rings for up to one month after the procedure. Re-piercing your ears should wait at least 6 to 8 weeks after the earlobe repair.

7. You may wear eyeglasses or sunglasses after the procedure.

8. There are no activity restrictions after the surgery. You may exercise at any level at which you feel comfortable.

9.   You may drive right after the procedure. Since most earlobe repairs are performed under local anesthesia, many patients drive themselves to and from the facility.

10.  If any redness, tenderness, or drainage develops from the earlobe after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery: Earlobe Repair and Reconstruction

Saturday, March 16th, 2013


Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the earlobe repair or reconstruction procedure. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all, of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.


There are no alternatives to surgical repair of a split or gauged (expanded) earlobe.


The goal of earlobe repair/reconstruction is to restore the size and form of the bottom portion of the ear.


The limitations to earlobe repair is how much natural earlobe tissue remains, whether it has any scar associated with it (e.g., keloid) and what the adjoining cartilaginous ear looks like.


Expected outcomes include the following: temporary swelling and bruising of the ear, a temporary firmness of the reconstructed earlobe, some mild discomfort of the earlobe, and temporary redness of the incision line/scar. It may take weeks to months before the final shape and optimal appearance of the earlobe is achieved.


Complications may include bleeding, infection, dehiscence of the incisional closure (part or complete separation), a prominent or noticeable scar, earlobe asymmetry from the other side, and a notch along the outer rim of the earlobe.


How the earlobe heals and the occurrence of complications can influence the final shape and appearance of the earlobe after it heals. Should complications or the desire to enhance the result further by additional surgery be needed, this will generate additional costs.

The Energing Trend Of Stretched Earlobe Repair

Saturday, January 14th, 2012

The adornment of ears has been around since the dawn of civilization. Women and men have been putting all sorts of jewelry on ears from the top of the helix down to the earlobe. In what some may consider out of the ordinary or more extreme, the non-cartilaginous portion of the ear (earlobe) has even been split, severed or expanded in the interest of aesthetic enhancement.

When one thinks of changing the size of the earlobe, thoughts are given to people from some remote island or tribes from more distant lands. But the trend of earlobe expansion that has been seen in the past ten years, that of gauging or inserts into the earlobes, is now commonplace right here in the U.S. While everyone is entitled to their own sense of beauty and body modification, expanded earlobes with large central holes with or without inserts is usually not going to be a lifelong expression for most people.

As a plastic surgeon I am seeing more young men present for surgical correction of the stretched earlobes. The most common reasons are either for employment or job promotion, entering the military service or they simply are tired of them. The first two are forced upon the person by having to mold into the conformity of the organization. The last reason is one in which one wants to undo a generational fashion statement that now makes one self-conscious with a lot of saggy earlobes. Such an appearance, as unfair as it might be, creates an impression amongst some that they know who and what you are.

Whatever the motivation for change, plastic surgery correction of stretched earlobes is an easy problem to fix. Stretching the earlobes creates too much earlobe tissue, even if the outer rim of it can be quite thin. It is always better to have too much tissue in which to do a reconstruction than too little.This is a basic axiom in plastic surgery. While the large amount of floppy earlobe tissue and its central oblong hole may look like an impossibility from which to create a unified smaller earlobe, it is actually straightforward to do. It can be done in the office under local anesthesia in less than an hour for both earlobes. So what may have taken a year or so to create by steadily increasing the gauge of the disc inserts can be undone in one hour of precision reconstruction to make the earlobe look normal again.

Recovery from such earlobe reconstruction is very minimal if at all. I use dissolveable sutures on both sides the earlobe which require no removal. No dressings are used and one only applies antibiotic ointment for the first week after the procedure. Showering, washing one’s hair and all normal activities can be done without interruption. Patients report no pain, bruising and minimal swelling. The earlobe looks normal immediately. Patients interestingly do report the feeling of ‘phantom lobes’, much like that of phantom limb syndrome after amputations. But there seems to be no problem adjusting back to what looks very similar to their original earlobes, albeit with a tiny vertical scar in the earlobe close to its attachment to the face.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Repair of the Torn Gauged Earlobe

Friday, May 13th, 2011

Background:  The earlobe has long been an anatomic location for personal adornment. From piercings to endless styles of ear rings, just about every conceivable variation of jewelry has been adapted to be applied to the earlobe. One of the more recent practices of earlobe fashion has been that or stretching or gauging the earlobe with the placement of various inserts.

By the gradual use of increasing size metal inserts, an earlobe hole is stretched out to some incredible sizes. This process of stretching is well known in plastic surgery as tissue expansion. The gauged earlobe is just a miniature version of it applied for cosmetic purposes to the diminuitive earlobe.

Like the lessons learned in tissue expansion surgery, the skin can be satisfactorily stretched provided that it is not done too fast or the skin stretched too far. In the case of the earlobe, the stretched earlobe rim of skin survives by the blood flow coming in from both ends. But when it gets stretched too thin, the blood supply is cut off and a central ischemic zone develops in which the skin dies. This causes the earlobe hole to be transformed into two hanging skin flaps as it falls apart.

Case Study: This 21 year-old man presented with a large split right earlobe. He had gauged both earlobes and, even though they were done with the same size inserts and at the same rate, the right earlobe fell apart while the left one remained intact. The earlobe had a large hanging posteriorly-based skin tube and a small anterior nubbin of skin (remaining earlobe) attached to the side of the face.

He underwent a right earlobe repair under local anesthesia. The posteriorly-based skin flap (tube) was shortened and the anterior nubbin’s skin edges were reopened. The two were re-attached to make a normal-sized earlobe and elimination of any remaining hole. It is an earlobe procedure that is not much more complex than a split earlobe repair and can be completed in about 30 minutes.

No dressing were applied and only antibiotic was used twice daily. He could shower and wash his hair the very next day. There is no problem getting reconstructed earlobes wet. While dissolveable sutures are placed on the back of the earlobe, those sutures on the front of the earlobe are removed one week later. The earlobes can be re-pierced in six weeks but never again can be stretched or gauged.

Case Highlights:

1)      Gauging of the earlobe makes an enlarged hole at the expense of the earlobe skin and blood supply. If stretched too quickly or too far, it can tear the remaining earlobe skin.


2)      The torn stretched earlobe presents two skin flaps (tubes) which can be shortened and put back together, restoring the original size and shape of the earlobe.


3)      A repaired gauged earlobe can sustain a secondary piercing but can never again be stretched or expanded.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Ear Keloid Removal With Skin Grafting

Thursday, February 24th, 2011

Background:  Keloid scars are one of the most difficult scar problems. They are hard to stop growing and removing them is no guarantee that they will not return. Their high recurrence rate is well chronicled. One of the reasons keloids can recur is that they are incompletely excised. Leaving but just a miniscule amount of keloid behind is all that it takes for it to regrow.

The ears are a frequent site of keloid development, particularly in the higher risk African-American patient. The high frequency of ear piercings, particularly multiple piercings, is the cause. While it will likely develop from an infected or complicated piercing, it can develop years later for no apparent cause also. The small size of the earlobe makes complete removal problematic if the keloid is of any size and one wants to maintain a normal earlobe shape.

Case Study: This is a 57 year-old female who had a slowly enlarging keloid on the back of her ear. It started two years previously from an uncomplicated piercing. The same earlobe had two other piercings which were normal. She has been through multiple steroid injections which, while helping with the itching and discomfort, did not shrink it in size. It appears The size of the keloid covered at least half of the surface area of the back of her earlobe and had begun to distort the more visible outer helical rim

Surgical resection was done by removing the entire keloid from the back of the ear as well as the involved earlobe hole. This left a large open wound on the back of the ear. Trying to close it would have left a small and distorted-looking earlobe. A full-thickness skin graft was taken from a more superior portion of the junction between the back of the ear and the mastoid skin. The donor site was closed primarily. The skin graft was sewn into the defect with small resorbable sutures.

The entire procedure took 45 minutes. A xeroform compression dressing (bolster) was applied with through and through sutures of 4-0 plain gut suture. No other dressing was used. The bolster was removed 10 days later with 100% graft take. At one year after surgery, no keloid recurrence has developed.

The use of a full-thickness skin graft on the back of the ear prevents a constrictive earlobe distortion after large keloid removal. Primary closure on the back of the ear when most of its skin has been removed will result in the earlobe being made smaller and looking pinched.   

Case Highlights:

1)      Ear keloids are very common and are caused by piercings. They usually start on the back of the ear. Once they develop, they often continue to grow and may be refractory to steroid injections.


2)      The typical size of many keloids and the small surface area of the earlobe makes earlobe distortion likely with excision and primary closure.


3)       Earlobe distortion can be prevented with keloid removal and ear reconstruction by full-thickness skin grafting of the defect. This approach gives one more leeway to remove the full extent of the keloid as severe earlobe deformity afterward is less likely.


Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Reconstruction of the Gauged Earlobe

Sunday, November 7th, 2010

Background: The adornment of the earlobe goes to back to nearly the beginning of mankind. Besides being a very visible piece of anatomy right next to the face, it is also easy to manipulate because it is composed of just skin and fat without more firm cartilage like the rest of the ear. Besides jewelry, the earlobe has been cosmetically altered by changing its shape. Making holes of various sizes in the earlobe allows for either an enlarged shape, the placement of an internal insert or both. This is done through the plastic surgery principle of tissue expansion. Known by the term of ‘gauging’, this allows the earlobe to be sequentially enlarged by gradually increasing the size of the internal insert.

Once done, the earlobe is forever altered and will always have an internal hole. Removing the inserts will allow the earlobe tissues to shrink down somewhat and the hole will always end up smaller than it was at its maximal diameter of expansion. If the hole enlargement was only fairly small (10mms or less), the hole will likely shrink to be fairly small. But larger diameters of expansion will not shrink completely back down to such a small hole. This is due to the skin being stretched beyond its elastic limits. If one is interested in reducing and reshaping their earlobe back to a more normal size and shape, surgical reconstruction will be needed.

Case: This is a 25 year-old male who had a history of both earlobes being enlarged four years previously. Now that he was engaged, at the request of is fiancée and his employer, he decided to rid himself of his enlarged earlobes. He removed his inserts and allowed the earlobes to shrink as much as possible over a period of six months. At their maximum size, they were about an inch in diameter. They did get smaller by about 50% and obtained a droopy deflated appearance.

Under local anesthesia, the holes and the excess tissue that hung down was excised. It is necessary to remove all skin that lines the enlarged hole edges. V-shaped skin flaps are designed and put together along the helical rim to prevent notching as it heals. Because he lived out of town and could not return for suture removal, it was closed with dissolveable sutures and topical glue for a dressing.

He went on heal without any problems and the earlobe scar was fairly indiscernbible. His case illustrates that reconstruction of the ‘gauged’ earlobe is simple and very effective. A normal earlobe size and shape can be obtained. The need for such earlobe reconstruction is increasing as some people decide to move on from this fashion trend or its correction is required by their potential employers or on entering military service.

Case Highlights:

1) Large amounts of gauging or internal expansion of the earlobe will not shrink completely back down. Ideally, one should allow six months to see how the hole will ‘close’ and have the earlobe tissues return to a more normal consistency.

2) One favorable benefit of the enlarged earlobe is that there is a surplus of earlobe tissue to work with during the reconstruction. This makes for a very favorable reconstruction situation.

3) Reconstruction of the gauged earlobe can be done under local anesthesia without any real recovery. It will result in a fine line scar down through the middle of the reshaped earlobe.

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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