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Archive for the ‘OR snapshots’ Category

OR Snapshots – Perioral Mound Liposuction

Sunday, January 22nd, 2017

 

There are numerous fat compartments on the face that can be surgically reduced. The most recognized and easily removed is the buccal fat pads. (aka buccal lipectomy) Located just under the cheekbones, it is a very discrete collection of fat that has its own pedicled blood supply and a surrounding capsule. It is removed from an intraoral approach through a small incision just opposite the molar teeth.

While the buccal fat is a large collection of fat compared to the rest of the face, it is frequently given more credit that it is due. Its removal affects the fullness of convexity of the cheek just under the cheekbones. It does not extend very low onto the face and its thinning effect will be relegated to the upper cheek area. If you drew a line from the tragus of the ear to the corner of the mouth, a buccal lipectomy has its effect above this line.

Perioral Mound Liposuction markings Dr Barry Eppley IndianapolisBelow this drawn line sits another smaller collection of facial fat known as the perioral fat or, when bulging, the perioral mounds. This is a subcutaneous non-encapsulated fat collection that sits between the skin and the buccinator muscle. It is located at the southern end of the cheeks or its lower half. It has no anatomic connection to the buccal fat pad. In rare cases the buccal fat pad has been known to fall or prolapse into the perioral mound area.

Removal of perioral mound fat is done by very small liposuction cannulas. It is never an impressive amount of fat that is removed but a little fat reduction does make for a visible external effect. It is a good companion to buccal lipectomies for a more complete cheek reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Two-Piece Custom Skull Implant

Saturday, January 21st, 2017

 

Skull reshaping using implants is the only effective method for augmenting head shape. While certain bone and muscle removals can be done for more limited skull reductions, skull augmentations can produce much more dramatic changes. In essence, the stretch of the scalp is far more permissive than the thickness of the skull bones.

In very large skull augmentations the scalp can become a limiting factor and may require a first-stage scalp expansion. But beyond the ability of the scalp to accommodate a large skull implant, getting the proper shape and dimensions of the implanted material is the other major challenge. This is overcome today using a custom design approach with a 3D CT scan. Custom skull implants can now be made to cover any area of the skull including the entire bony skull if desired. (forehead back to occiput)

Two Piece Custom Skull Implant Dr Barry Eppley IndianapolisManufacturing very large or total custom skull implants is difficult because they can cover more than a 180 degree arc with thin edges. To avoid manufacturing problems, a two-piece approach to the implant’s fabrication and insertion can be done. Creating two interlocking edges allows for a two-piece custom skull implant to be accurately reassembled on the patient’s skull the way it was designed.

Very large skull implants are most accurately placed using a long scalp incision. This patient shown here already had a full coronal incision so its total length was used. If such a long scar was not already present, a shorter incisional length could be used.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Macroporous Custom Skull Implant

Wednesday, January 11th, 2017

 

Custom skull implants have become a reliable and safe method of various types of skull augmentation. Made from the patient’s 3D CT scan, they cover the desired skull surface with a precise fit and a smooth outer surface that blends well into the surrounding bone/muscle areas. The most careful judgment has to be made in the thickness of its design so a competent and not overly tight scalp closure is obtained.

An obvious but often overlooked feature of most custom skull implants is that they are ‘large’. They can cover a significant surface area of the bony skull. This places an implant between the thick overlying scalp and the bone. While I have never seen this to cause any problems, it would be desirous to have some increased fibrovascular connections between the scalp and the bone. Since a silicone skull implant is not naturally porous this is not a biologic property such an implant would naturally have.

custom-skull-implant-ready-for-placement-dr-barry-eppley-indianapolisTo help achieve some integration of skull implants with the surrounding tissues, the concept of perfusion holes is used. This is were many 3mm to 4mm circular holes are placed through the implant. They can be thought of as ‘perfusion holes’. They will permit a very rapid tissue ingrowth through them, reconnecting the scalp and the bone with these tissue connections. They also serve to take one large implant pocket and make it many small pockets through this natural tissue quilting effect.

While these perfusion holes also help to fix the implant more securely into place, it does not make it any more difficult to remove or modify it later should the need arise. The tissue bands can be broken fairly easily in that process.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Open Rhinoplasty

Sunday, January 8th, 2017

 

Rhinoplasty surgery requires incisional access to perform osteocartilaginous reshaping. The most common historic technique was the ‘closed approach’ where all incisions were placed inside the nose. Because this provided limited visual access it took a lot of experience to master aesthetic nasal surgery. This was the standard in rhinoplasty until the 1990s were it was surpassed in usage by the ‘open approach’.

open-rhinoplasty-indianapolis-dr-barry-eppleyThe open approach degloves the skin off the tip of the nose and permits complete visual access to the entire underlying nasal structures. What makes it possible to expose the nose is the mid-columellar incision. This extra 6mms of skin incisional length connects with intranasal mucosal incisions to allow the nasal tip skin to be lifted off of the lower alar cartilages. While once controverial, the open rhinoplasty has become the standard technique in rhinoplasty today as it produces consistent and more reliable surgical outcomes.

Patients are often understandably concerned about a visible nasal scar with the open nasal approach. But the columellar skin heals so well that such a scar is virtually invisible in most patients. It rarely causes a scar problem and I have never seen a hypertrophic or keloid columellar scar. The only occasional columellar scar problem seen is a stepoff or notch along one of its sides due to less than perfect closure or premature incisional separation.

Interestingly, the widespread use of the open approach has led to a re-emergence of the closed approach. Now known as the ‘scarless’ rhinoplasty, the use of the closed approach is refinding a role in certain types of nasal reshaping surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Abdominal Panniculectomy (Apron Removal)

Tuesday, January 3rd, 2017

 

The abdominal panniculectomy procedure is well known to be a ‘big’ operation. It is the supersized version of the traditional tummy tuck and is often judged by the weight of the pannus removed. The largest abdominal pannus I have ever removed is 85lbs and that was back in the pre-bariatric surgery era…when the abdominal panniculecomy was the only form of bariatric or weight loss surgery.

abdominal-panniculectomy-surgery-dr-barry-eppley-indianapolisOne of the challenges in this operation is to manage the considerable soft tissue mass, removing the most abdominal tissue that one can while still being able to close the wound without creating after surgery healing problems. When removed the abdominal pannus looks even bigger than when it is attached and hanging on the patient. The term ‘pannus’ is often associated with the word ‘apron’. It is easy to see why it might have that name as seen in this intraoperative picture where it could be worn like an apron once removed.

Beyond the light-hearted clothing analogy, the abdominal panniculectomy produces a dramatic improvement for the patient in many ways. It eliminates chronic skin infections and sores that develop underneath it and removes stressful weight from the back and knees that have to support and carry it around. It also allows the patient better clothing options, often allowing them to find outfits that fit better.

The abdominal panniculectomy is often thought of as a tummy tuck…and it is. But it is an operation that is much bigger in magnitude than most traditional tummy tucks as can be seen by the type of patient on which it is performed. White it is associated with a relatively significant rate of complications, like fluid collections and wound healing issues, these are often self-resolving issues and do not ultimately detract from the huge benefit that patients receive as a result from undergoing the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Injectable Diced Cartilage Grafting Technique

Monday, January 2nd, 2017

 

Rib grafts are a well known autologous graft in rhinoplasty for significant augmentation. The rib graft can be used as either a solid piece (en bloc) or can be diced into very small cubes and turned into a sausage-like wrap. Both rib graft methods have their advantages but the diced technique effectively eliminates any chance of graft warping, the most common aesthetic complication of onlay rib grafting in the nose.

diced-cartilage-graft-rhinoplasty-preparation-dr-barry-eppley-indianapolisBut the wrap containment method is not the only way to use a rib graft. For smaller dorsal defects diced rib cartilage can be placed through an injection method. If one has enough septal cartilage this can also be used similarly. In this method the diced cartilage is loaded into a 1cc syringe with an open barrel. (this has to be cut that way) This creates a loaded injectable cartilage graft syringe.

The key to using this cartilage grafting method is that it has to be placed through a narrow tunnel to the dorsal defect site. The tunnel serves as the containment method. Once inside the tunnel the graft is injected on withdrawal. It can then be molded into shape although the tunnel itself has already made most of the graft shape. The shape is held by the application of external tapes/splint.

It is easy to see that this is a linear grafting method that works by the alignment of the syringe for graft placement. This makes it best used for dorsal line defects from the radix down to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Aesthetic Temporal Artery Ligations

Saturday, December 31st, 2016

 

Prominent bulges in the temporal region are almost always caused by the temporal arteries. The superficial temporal artery comes off the facial artery in the neck and courses upward in front of the ear. Once it reaches a typical landmark point of 1 cm in front of the ear and 2 cms about that point, it bifurcates in to a Y pattern. The front part of this takeoff is the anterior branch of the superficial temporal artery and it continues towards the forehead in a very tortuous pattern.

This anterior branch of the temporal artery is fairly superficial and is prone to becoming visibly enlarged. Why it does so is not precisely known but it occurs far more commonly in men. (although it does occur in women as well) It can become quite noticeable with exercise, heat, alcohol intake and a low head position.  It can sometimes be associated with temporal headaches as well.

When the procedure of temporal artery ligation is considered, what is done for prominent temporal arteries is quite different than the historic approach of simple ligation. The original temporal ligation procedure, also known as a temporal artery biopsy, was done to diagnose arteritis or autoimmune conditions. This is where an incision was made behind the temporal hairline and a section of the artery is removed. This is a single incision which is fairly large by aesthetic standards.

temporal-artery-ligation-dr-barry-eppley-indianapolisThe aesthetic temporal artery ligation procedure is a multi-incisional technique that strategically places ligation points at select points along the course of the artery into the forehead. This is always at least two points and often three. These are very small incisions that take into account the wrinkle lines of the forehead when placed in that location. They heal exceptionally well and leave little to no trace of a scar.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Diced Rib Graft Rhinoplasty

Saturday, December 31st, 2016

A significant build-up of the nose requires a combination of bridge and tip augmentation. In primary rhinoplasty this is usually needed in many ethnic patients who lack nasal projection from the face. This may also be required in revision rhinoplasty when over reduction has been done from a prior procedure. In such cases the key element of the surgery is an adequate volume of cartilage grafts.

The most common source of an undisputed volume of cartilage is a rib graft. The ribs offers an unlimited amount of cartilage for the nose no matter where on the ribcage it is harvested. Despite this huge advantage, rib cartilage has a major disadvantage….it is not straight. Nowhere on the rib cage is a cartilaginous section perfectly straight. In addition it almost always has to be carved, removing perichondrium in the process. This further potentiates the risk of graft warping after surgery.

diced-rib-graft-rhinoplasty-dr-barry-eppley-indianapolisThe one proven method to eliminate the risk of rib graft warping in rhinoplasty is diced modification. Rather than place one single solid piece of rib, the graft is cut into many small pieces or small cubes. The diced rib is cut down to as small as 1 x 1mm pieces. The diced rib is then wrapped in either fascia, cadaveric dermis or collagen to create a moldable sausage-like implant. This wrapping contains the diced graft so it can be inserted and molded once placed onto the dorsum of the nose.

Diced rib grafting offers not only a customizable approach to significant nasal augmentation but a rapid integration/healing of the graft. The many small cartilage pieces allow for early and substantial fibrovascular ingrowth into the graft. This is evidenced by the very firm feel of the diced rib graft just a few weeks after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Liposuction and Boiling Fat

Thursday, December 29th, 2016

 

Liposuction is one of the most common and recognized procedures in plastic surgery. By the way it looks in watching the procedure and how it is commonly perceived by the public, liposuction appears to be as simple as ‘sucking fat out’. But the reality is that it is a more complex extraction process than its name alone implies.

The obvious part of liposuction is the insertion of a hollow stainless steel cannula under the skin. Traditionally a back and forth motion of the cannula is done which essentially cuts tunnels through the fat layers often from multiple different directions. (known as cross tunneling) The cannula is attached by tubing to a vacuum pump which then pulls out the cut or loose fat as well as introduced and other bodily fluids.

boiling-fat-in-liposuction-dr-barry-eppley-indianapolisBut working more occultly are several basic principles of physics that really make liposuction work. One of these can be occasionally observed in the fat collection canister. Looking carefully, or sometimes not very carefully, one can see bubbles coming up from the bottom of the fluid collection to its surface. Sometimes there are so many bubbles it appears that the fat is ‘boiling’.

This bubbling action in the collected fat aspirate occurs because of the vapor pressure of water. All liquids at any temperature exert a certain vapor pressure. This can be thought of at the point where liquid molecules are escaping into the vapor phase. This transition is highly influenced by temperature, the higher the temperature the more the molecules become active and can break free of their intermolecular bonds and escape into the atmosphere. (exceeding the atmospheric pressure pushing down on it). This is well known in water where at roughy 212 degrees F at sea level the vapor pressure is large enough that bubbles are formed.

This is where the influence of atmospheric pressure plays a critical role. At standard atmospheric pressure (1 atmosphere), water boils at 212 degrees F. In essence the vapor pressure of water at 212 degrees is 1 atmosphere. At higher elevations where the atmospheric temperature is lower, water boils at a lower temperature as there is not as much pressure on the liquid water as the water vapor reaches that pressure at a lower temperature.

The vacuum pump of liposuction creates a negative pressure in the collection cannister. The normal negative pressure setting is at least -20cm of water or – 1 atm. This will dramatically lower the boiling point of water or, thinking of it non-thermally, will allow the liquid water to escape into a gas. (bubbles) This is what is happening at a fluid temperature that is somewhere just below body temperature. The collected fat and fluid is truly boiling!

Dr. Barry Eppley

Indianapolis, Indiana

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


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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