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Dr. Barry Eppley

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Archive for the ‘OR snapshots’ Category

OR Snapshots – Custom Buttock Implants

Wednesday, December 6th, 2017


While the most common form of buttock augmentation today is fat grafting (Brazilian Butt Lift surgery or BBL), buttock implants still have a role to play. They are the only other method of surgical buttock augmentation for those patients who do not have enough fat to harvest for a BBL or have failed previous BBL efforts due to fat absorption.

Like all aesthetic implants used in the body, buttock implants provide permanent volume in a single surgical effort. But the final outcome both in volume and shape is determined by that of the implant’s design. Buttock implants come in both round and anatomic designs and volumes up to 700ccs. While the pocket location can be either intramuscular or subfascial, larger buttock implants sizes have to be placed on top of the gluteus maximus muscle.

One of the design problems in larger buttock implants is that they often can result in a ‘bubble butt’ appearance. This is caused by the high projection compared to the base diameter of the implant. While breast implants are designed to look spherical, such an appearance for the buttocks is not as desired by most patients. To get a more natural look, custom buttock implants have a wider base diameter with less projection. The concept is that in the buttocks, the diameter of the implant is more important than its projection.

Custom buttock implants are designed to be used in the subfascial location. Their broad base diameters, up to 18 cms, cover more buttock surface area and blend in more naturally to the surrounding tissues. This is particularly important out laterally into the hip area. With a broader base diameter the projections can often be lower than 6 cms or less.

The base diameter of custom buttock implants mandates that they be placed in the subfascial position rather than in the intramuscular location. This also allows for a greater influence on the hip region that would otherwise be obtainable.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – ePTFE Premaxillary-Paranasal Implant

Monday, December 4th, 2017


Increasing the projection of the central midface at the base of the nose and upper lip involves augmenting the bony perimeter of the pyriform aperture. This anterior bony opening in the maxilla leads into the nose. At its more narrow end superiorly are the nasal bones. At its larger lower end the bone curves down and inward and meets in the middle to create the anterior nasal spine.

From an implant augmentation standpoint the pyriform aperture region has two distinct zones, the lateral paired paranasal regions and the central premaxillary region over the anterior nasal spine. The paranasal region has a flat or slightly concave surface while the premaxillary region is distinctly convex with a more V-shape projection to it. These anatomic central middle regions can be a augmented by three different styles of implants, paranasal, premaxillary and a combined premaxillary-paranasal implant.

Because of the tree different zones of potential augmentation and the very limited implant styles available, this is a very confusing area for surgeons and patients alike. The only preformed facial implant available is the peri-pyriform silicone implant. By its name and shape it is a premaxillary-paranasal implant since it covers all three zones. But it can be sectioned in the middle and turned into just paranasal implants if desired.

Another option to make a complete premaxillary-paranasal implant is to carve it out of an ePTFE block. Shaped almost like a moustache, the adaptability of this material allows it to be molded into placed over the central projecting spine and around the more concave sides into the maxilla. It may look large when positioned on the outside of the patient but it needs a lot of material to properly cover this central midface area.

The premaxillary-paranasal implant is placed through an intraoral incision under the upper lip. The key is to make the incision high enough on the lip side of the vestibule to maintain a good musculomucosavl cuff of tissue to close over the implant with a two layers of suture.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Hourglass Figure Surgery

Wednesday, November 29th, 2017


Altering the shape of a woman’s body has been a part of plastic surgery for over fifty years. This has traditionally meant such procedures as breast augmentation, liposuction and tummy tucks. In the most contemporary forms of female body contouring the role of the buttocks and hips, once deemed undesirable, have become popular. This has added buttock and hip augmentation using either fat transfer and implants to the options available for body reshaping.

The hourglass figure shape is one in which there is larger breasts, a narrow waist and hip widths similar to that of the breasts. In its most extreme form it has an appearance to that of an actual hourglass with a wide upper and lower half and being narrow in circumference between the two halves. Some deem such a female body shape as more desirable than others. Between the options available in plastic surgery and the use of traditional corsets the hourglass shape today is more attainable than it has ever been.

One newer addition in hourglass figure surgery in is that of rib removal. Reductions in the lengths of ribs #10, 1 and 12 removes the last rigid anatomic restriction to maximal horizontal waistline reduction. This procedure is only appropriate when the more traditional use of liposuction has already been done to reduce any fat collections around the waistline. When combined with other body contouring procedures such as buttock augmentation (in this picture with buttock implants), the hourglass figure may become a reality.

Hourglass figure surgery has numerous options to both augment the upper and lower half as well as narrow what lies in the middle. Larger breast implants, custom buttock implant designs and rib removal represent options for those women that seek a maximal approach to altering their body into more of the hourglass shape..

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Safe Limit of Fat Removal in Liposuction

Wednesday, November 29th, 2017


Liposuction is the most commonly performed cosmetic body contouring procedure, both by number of patients and body surface area. It has undergone a lot of technical improvements over the past third-five years from patient indications to the technical equipment needed to perform it.

While understandably viewed as an aesthetic procedure, its traumatic impact on the body is often overlooked. The small skin entrances for the introduction of the fat-sucking cannulas belies the generalized injury to the subcutaneous tissues which has been treated. The trauma to the fatty tissues and all that runs through it is considerable. Any patient that has had the procedure can testify that its recovery is usually greater than they could have anticipated both in terms of swelling and bruising and the time it takes for its resolution.

The trauma to the body and how it responds to it has been well appreciated with the most extreme form of it in large volume liposuction. This term has become known as any amount of fat removal that exceeds five (5) liters. When fat is removed in a singe setting at greater than this volume, the effects on the body result in fluid shifts and blood loss that can result in potentially major complications. At the least it prolongs the recovery time and can take more than month after surgery for the patient to feel more normal again. Numerous adverse outcomes from the 1990s, when large volume liposuction became popular, proved that whether it can be done should be preceded by whether it would be done.

If one wants a large amount of fat removed it should be done in stages given that liposuction is an elective procedure.  While the five liter limit is not an absolute, as it should really be based on body weight or even body surface area, it does serve as a good clinical guideline.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Silicone Testicle Implant Replacement

Monday, November 20th, 2017


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

OR Snapshots – Custom Sterno-Pectoral Implants in Pectus Excavatum

Thursday, November 16th, 2017


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

OR Snapshots – Submental Approach to Chin Reduction

Friday, November 10th, 2017


The chin is the projecting feature of the lower face and consists of combined bone and soft tissue. While the chin may be more commonly recognized for treatment of deficiencies in its size and projection, it is also prone to the opposite issues of excess and sagging. Chin bony overgrowths (hyperplasia), chin pad sagging (ptosis) and hyperdynamic chin pad protrusions are all a collection of aesthetic chin prominences.

Unlike augmenting the chin with an implant or moving the bone which can be done in an intraoral scarless manner, decreasing the size of the chin can rarely be so done. By definition most chin excesses are a combination of bone and soft tissue which must be both addressed for an effective aesthetic change. This eliminates the use of an intraoral approach in many cases as this access provides no method for soft tissue removal or tightening. The intraoral approach can be used to try and lift up the sagging chin pad in some cases of ptosis but this has very variable amounts of success.

When using a submental approach for chin reduction, the key is the location and length of the scar. The incision and resultant scar must be placed far enough back under the chin so it does one end up on the visible anterior edge of the chin. But the length of the scar is also of critical importance to limit its potential visibility. When removing redundant soft tissues (submental excision and tuck), it is easy to end up chasing redundancies at the end of the incisional closure and have a longer scar that one may have initially anticipated. If the scar becomes too long or curves up at the ends it may become visible from the side.

The method that I use to eliminate the risk of a long submental scar that may become visible is to keep it within the width of the sides of the mouth above. Dropping a vertical line down from the mouth corners and angling it inward as it crosses the jawline into the neck provides the limit of how far the submental scar line can extend out laterally. These marked lines provide a guideline during a submental chin reduction of how aggressive one can be.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Head Widening Temporal Implants

Thursday, November 9th, 2017


The width of the head is determined by how wide it is above the ears.  This is known as the temporal region and consists of a very uniquely shaped temporal bone and varying thicknesses of the temporals muscle over it. By the eye the temporal bone is very concave and the temporalis muscle is correspondingly very thick. (anterior temporal zone) Back by the ears, the temporal bone is much thinner, has a convex shape and the overlying temporalis muscle is much thinner. (zone 2)

While the side of the head is really comprised of both temporal zones, the perception of its width is determined more by the zone 2 region than zone 1. With a more narrow head width the shape of the head above the ears may be either a straight vertical line or even tilted in with a more narrow temporal line distance across the top of the head.

The narrow head can be effectively widened through the use of specially designed temporal implants. Placed either above the muscle in the subfascial plane or between the muscle and the bone (this is based on incisional access), the side of the head can be substantially widened. Traditional use of temporal implants is for the anterior or zone 1 region and by comparison these performed implant are relatively small. But when covering all of the zone 2 region and the poster part of one 1, head widening implants cover a far greater surface area.

The size of head widening temporal implants suggests that they would be hard to surgically place, but they often are not much thicker than 5mm to 7mms. Because there are two sides to the head, a pair of head widening temporal implants causes a more substantial widening effect that one may think based on the numbers alone.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapsots – Vertical Lengthening Genioplasty (Bony Chin Lengthening)

Wednesday, November 8th, 2017


The chin occupies the most prominent part of the lower third of the face. This is why it is the subject of many different chin reshaping options. The most common dimensional chin change is one of an increased horizontal projection. This can be done using either an implant or an advancement bony genioplasty, each with their own advantages and disadvantages.

The chin can also be vertically lengthened which is indicated when the lower third of he face is disproportionally deficient. Just like cutting the chin bone and moving it forward, it can also be cut and vertically lengthened. Known as a lengthening bony genioplasty, it is held in its lowered position by a small spanning titanium plate with screws. While it can be vertically lengthened by any amount, it usually takes up to 8 to 10mms to see a significant external chin lengthening change.

Since this type of facial osteotomy exposes the marrow space of the chin bone on both side of the bone cut and the down fractured chin segment is well vascularized through the maintenance of his inferior soft tissue attachments, it is likely some bone healing would naturally occur in the gap space. But with a bony gap that may be up to 10mms, I prefer to graft that gap to allow for maximal bone healing between the superior and inferior bony chin segments. This is most needed in the central area where the gap distance is the greatest. The size of the gap becomes less at the sides of the chin where it tapers down to actual contact between the upper and lower segments. Graft options include cadaveric bone and synthetic hydroxyapatite blocks.

A pure vertical lengthening genioplasty is very effective at chin lengthening and is the ‘least’ traumatic of all bony chin movements since the bone segment is merely opened to create the dimensional change.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Tail of the Brow Bone Reduction

Sunday, November 5th, 2017


Brow bone reduction is a well known aesthetic procedure for reducing the horizontal projection of the lower forehead. Done by either burring for minor changes or an osteoplastic bone flap setback technique for more major setbacks, the horizontal position of the brow and/or its convex shape can be reduced. But no matter what brow bone reduction method is used, it almost always requires an open approach through a hairline or coronal scalp incision.

But the horizontal reshaping of the brow bones is not the only dimension in which it can be changed. Vertical brow bone reduction can also be done. This may be performed when the brow bone is sitting too low into the orbit, particularly the tail of the brow bone. This may be indicated in reducing the exposed or skeletonize brow bone after a browlift, for a congenitally short orbital height, in vertical orbital dystopia to even out the superior orbital rims or to try and increase the vertical opening of the eye.

Unlike traditional brow bone reduction surgery, vertical brow bone reduction is done through an upper eyelid incision. This provides direct access to the lower edge of the brow bone which is to be reduced by a burring technique. Because the outer half of the brow bone does not contain the frontal sinus, significant reduction of it can be done. The outer half of the lower edge of the brow bone can be removed to create an increased vertical distance between the superior and inferior orbital rims. Excessive projection of the tail of the brow bone can also be done to reduce its prominence through a combined vertical and horizontal bone removal.

Transpalpebral brow bone reduction is largely about reshaping the outer half or tail of the brow bone. The upper eyelid offers both direct and good aesthetic access to perform it.

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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