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Dr. Barry Eppley

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Archive for the ‘OR snapshots’ Category

OR Snapshots – Facial Cyst Removal

Saturday, July 15th, 2017


Lumps and bumps of the face are common. They are usually located in the subcutaneous layer right beneath the skin and, in some types, are directly attached to the underside of the skin. The most common pathologies are sebaceous cyst, dermoid cyst and lipoma. While they are benign they will usually continue to grow. While initially felt as a small non-visible lump, they often create an external distortion as they grow.

Facial cysts are mostly a cosmetic concern provided they do not get infected. (dermoid cysts and sebaceous cysts can, lipomas will not) While they can be quite disconcerting when they are found and they often continue to grow slowly, they can be removed in most cases with minimal scarring if done properly. Unsightly scars can make the facial area look worse in appearance than the original pathology.

While placing the incision in a skin crease away from the facial lesion site has the advantages of a more hidden scar, this is not always possible to do. The commonly used method is with a small skin incision directly over the lump. This also has the advantage in dermoid cysts that the attached skin pore is also completely removed to avoid cyst recurrence. In most cases the incision will need to be almost as long as the mass to ensure that its walls and contents are completely removed. These can be done under local anesthesia in the office in teens and adults. Infants and children will require an anesthetic to perform it.

As long as the incision is placed parallel to the relaxed skin tension lines of the face, even though it is in an exposed area, the scarring will be quite acceptable. Skin closure of these facial lesions excisions is often done in a subcuticular technique so no sutures need to be removed and no suture track marks all be left behind.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Titanium Cranioplasty

Tuesday, July 4th, 2017


Reconstruction of the skull can be done using a variety of alloplastic materials. Over the years synthetic cranioplasties have evolved from solid metal plates to bone cements to computer-generated implant replacements of lost bone.  While some techniques are most historic than others, each still has a role to play in contemporary cranioplasty surgery.

When there js adequate time to have a 3D computer-generated implant reconstruction done, this is almost always the preferred method for large full-thickness skull defects. The strength of the materials (HTR, PEKK, PEEK) and their exacting fit makes them as ideal as possible for a non-autogenous reconstruction.

But when time does not permit the necessary fabrication time for a 3D implant, several alternatives exist. One option is that of bone cement. While there are several different types of bone cements, they will require a backing for their use in large full-thickness skull defects.  The hydroxyapatite bone cements, in particular, do not have enough strength when wet to resist displacement and potential fracture. Even with traditional PMMA bone cements, a rigid backing is still structurally beneficial

The best intraoperatively fashioned backing for full-thickness skull defects is titanium mesh. It comes in a variety of geometric configurations. But the hexagonal pattern allows for the most malleability of its shape and adaptation to the surrounding bone edges. It also has a lot of metallic  edges onto which bone cements can grab onto in the setting and curing process of the material.

While traditional metal cranioplasty refers to an outer solid cover over the defect, a mesh metal cranioplasty refers to its use as a backing for bone cement materials. If a mesh material is placed in the outer surface of the bone alone, tissue contraction around its mesh shape will eventually reveal these irregularities particularly in the exposed forehead area.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Cartilaginous Ends

Monday, June 26th, 2017


Rib removal is the last surgical option for maximal waistline reduction. After liposuction the only remaining anatomic obstruction is the lower ribcage. The outer and downward flare of the free floating ribs does influence the width of the waistline at the horizontal level of the umbilicus. Contrary to its perception rib removal is not a myth or an urban legend but an actual procedure that is both safe and effective. The aesthetic tradeoff is the small fine line scar on the back which is needed to do the procedure.

Rib removal is really subtotal rib removal, only the outer portion of the rib is removed. There is no aesthetic benefit to removing the whole rib by disarticulating it from its vertebral facets. The rib only needs to be removed back to the outer edge of the erector spinae muscle. At this point a full-thickness bony cut is done to separate from its medial attachment.

The rib is then dissected out laterally in a circumferential suboperiosteal fashion until its cartilaginous tip is reached. At the cartilaginous end numerous muscular and fascial attachments exist. These are easily stripped off. Thus aesthetic rib removal involves only one bone cut per rib as the distal end is ‘free’. (not attached to bone but its does have soft tissue attachments.

In some cases of rib removal for maximum effectiveness, rib #10 is also removed in a subtotal manner also. Even though it is not a true free floating rib it still has a cartilaginous attachment to the anterior subcostal ribcage at the 7-8-9-10 cartilaginous unit.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Graft Tip Rhinoplasty

Thursday, June 22nd, 2017


While many rhinoplasties are reductive in their overall reshaping effect, some require the addition of support or structure through the use of autologous tissue grafts. Most noses can be satisfactorily augmented or rebuilt through the use of septal, ear or combining septal and ear cartilage grafts. But when such local and regional cartilages harvest sites are depleted or inadequate for the amount of augmentation needed, the rib is the remaining ‘go to’ cartilage donor site.

Rib grafts offer an unlimited supply of cartilage graft material when it comes to what is needed in the nose. Regardless of where it is harvested (inframammary or subcostal incisions), the amount of donor material is more than adequate. Issues such as curved cartilage shapes (ribs are rarely perfectly straight) and whether full-thickness or in situ harvesting methods are used may pose some graft limitations But these are overcome by experienced harvesting techniques.

In the tip of the nose, rib grafts are needed when considerable tip lengthening or derotation changes are needed.  (rib graft tip rhinoplasty) Placing an L-shaped cartilage construct at the end of the nose has a powerful tip augmentation effect which is only limited by the ability of the skin to stretch over it and still have adequate perfusion after surgery.

Rib grafting to the nasal tip is often an onlay technique where the grafts are placed over the existing medial footplates and dome cartilages. A pocket is made under the columellar skin below the incision down to the anterior nasal spine into which one carved piece of the tip graft is placed. (vertical graft component) A lower dorsal-dome cartilage graft (horizontal component) is fashioned and placed on top of the existing dome cartilages to be united at 90 degrees to the columellar piece. Suturing the two rib grafts together creates the new tip defining point.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Neurovascular Bundle Preservation in Rib Removal Surgery

Monday, June 12th, 2017


Rib removal can be done for a variety of aesthetic and medical purposes. The most common aesthetic reason is for horizontal waistline narrowing with the subtotal resection of the truly free floating ribs. (#s 11 and 12) Through a small obliquely oriented skin incision on the back the midportion of the ribs are identified just lateral to the erector spine muscle and cut. From that position the rib is then dissected out to its cartilaginous tip and removed.

One of the keys to rib dissection is that it is done in a subperiosteal plane. The periosteum is tightly wrapped in a circumferential manner around the bony rib. Getting under this tissue layer allows for the smoothest and cleanest plane of dissection but also preserves all surrounding structures. This is most relevant to the neurovascular bundle that sits in a groove on the inferior side of the rib. Elevating and preserving the artery and vein makes not only for less intraoperative bleeding but prevents inadvertent nerve injury/transection and the potential for chronic postoperative rib pain.

The subperiosteal rib plane of dissection is easiest on its superior aspect and harder to get out the neuromuscular bundle from its inferior bony groove. But the same instruments that are used to dissect the mucoperichondrium from the nasal septum are used to get the neuromuscular bundle out of its bony groove. Once started more proximal it is much easier to elevate out to the cartilaginous end of the rib. Once the rib is removed the vessels and nerve should be seen intact in the periosteal soft tissue cuff.

Rib removal is often associated with a destructive and very invasive surgery, undoubtably influenced by thoracic surgery  which has a different intent for its performance. From an aesthetic stand point it is important that rib removal be doing through small incisions and minimize any risk for chronic postoperative pain from intercostal nerve injuries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Extended Temporal Implant

Sunday, June 11th, 2017


Temporal hollowing is commonly treated by injectable fillers and fat injections. While both of these injection methods have their merits, the assured permanent temporal augmentation method is with the use of an implant. Temporal implants are newer forms of facial implants that are specifically designed to replicate the soft feel of muscle rather than that of bone. It is the only facial implant that is designed to augment a soft tissue area.

Temporal hollowing is the result of fat atrophy, muscle wasting/thinning or a combination  of both. In modest to moderate amounts standard temporal implants do well in improving hollowing. They cover the lower half  of the temporal region from the zygomatic arch upward to the level of lateral brows.

In more severe forms of temporal hollowing the concavity extends up to the anterior temporal line at the side of the forehead. This encompasses the entire anterior temporal zone for which the standard implant is deficient in height. (vertical length) As a result an extended temporal implant has been designed that can augment the entire extent of temporal hollowing should it go all the way up to the forehead.

The extended temporal implant is placed through the same incision as the standard style. The length of the incision does not need to be extended to properly place it. Once the pocket is made the implant is inserted in a horizontal orientation and then turned 90 degrees for proper placement.

The extended temporal implant offers enhanced improvement for those so afflicted with more severe facial hollowing. Thin females, patients with medication-induced facial lipoatrophy, and extreme weight loss patients are the most common aesthetic indications for use of the extended temporal implant.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Submental Chin Reduction Incision

Wednesday, June 7th, 2017


Chin reduction is a far more challenging operation in many ways than chin augmentation. Unlike chin augmentation, which rarely has to consider the overlying soft tissue because it stretches it out, this is a major consideration when making the chin smaller.  While the chin bone can be reduced in all of its dimensions (height, width and projection), the overlying chin soft tissue pad and the tissues on the underside of the chin do not magically shrink down when its bone support is lessened.

In cases of minor chin bone reshaping an intraoral approach may be effective and not cause adverse soft tissue effects. But the risk of creating a witch’s chin and submental soft tissue redundancies becomes very real as the chin bone reduction becomes greater and more of its soft tissue attachments are released.

The soft tissue issues are not ameliorated by an intraoral sliding genioplasty technique for horizontal chin excess. While cutting and sliding the chin bone back does keep inferior border soft tissues attached and reduces the risk of a witch’s chin deformity, it causes submental fullness as the attached soft tissues get pushed back.

The role of the submental chin reduction technique is that it manages both bone reduction/reshaping and removes/tightens the overlying soft tissues. It accomplishes both tissue reductions by an external skin incision in the anterior submental region. While the resultant scar is always a nervous trade-off, good placement and limited lengths make for a favorable scar outcome.

The key to the submental scar is its initial placement on the back edge of the inferior border and in a curved fashion. Its length should never exceed vertical lines drawn down from the mouth corners even during closure if working out dog ears are necessary. The incision should stay within the confines of the mouth width. The other key is when removing soft tissue excess, int is actually worked out of the neck not the soft tissue chin pad. This prevents the resultant scar from ending up on the front edge of the soft tissue chin pad where it could become more visible.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Temporal Reduction for Head Width Narrowing

Saturday, June 3rd, 2017


The size of one’s head can be judged from different dimensions. One of these dimensions is head width, which is judged by the appearance or size of the head above the ears. A normal head width does not stand out and has either a flat to a very slightly convex shape. It lies well inside a vertical line drawn up from the superior arch of the ear. A narrow head width has a straight line or concave appearance between the superior temporal line and the ears.

Conversely, a wide head has a distinct convex shape that bows outward above the ears. Its width may equal the protrusion of the ear. In very large head widths the tissues may even make the top of the ear sticks out at its helical root attachment.

The side of the head is anatomically composed of bone, temporalis muscle and skin. It is structurally simple and there are no vital blood vessels or nerves in the area. What is often not appreciated is how much the temporalis muscle thickness contributes to the width of the head. Even though the posterior temporal muscle belly is far thinner than its anterior portion, it still has a thickness of 5 to 7mms. (if not more in most men)

Understanding the thickness of the posterior temporalis muscle serves as the basis of the temporal reduction procedure. Removing the entire thickness of the muscle can result in a very visible and distinct narrowing of the side of the head. In so doing there are no functional implications of jaw motion due to the remaining larger anterior muscle belly.

The key in doing posterior temporal reduction is the incisional access. A long vertical incision on the side of the head is not aesthetically acceptable for most patients. A more limited incision for its removal must be used. This can be either a completely postauricular incision or a combination of an upper postauricular incision with a small vertical extension above the ear. The muscle is released in a subfascial manner and then delivered through the much smaller incision.


Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Greater Occipital Nerve Decompression

Thursday, May 18th, 2017


Migraine surgery has become popular for the few select headache patients who fulfill specific selection criteria. Having reproducible headache symptoms that correlate to specific cranial nerve locations makes the concept of nerve decompression potentially successful. Based on the premise the nerve is being pinched as the initiator of the headache attacks serves as the biologic basis for the surgery.

One of the most nerve sites treated in migraine surgery is that of the greater occipital nerve. Known to be a major contributing factor in occipital neuralgia (cervicogenic headaches), it is a spinal nerve from the 2nd cervical spinal nerve. It emerges from between the first and second cervical vertebrae up through the deep neck musculature through the trapezius muscle and fascia to innervate the skin of the back and top of the scalp. It can become entrapped as it passes through the muscle and fascia.

Greater occipital nerve decompression is done through a midline incision at the low end of the occipital hairline. Dissection is done through the thick layer of subcutaneous fat down to the trapezius fascia. The fascia is opened in the midline and the nerve is dissected out from the underlying muscles. Once identified the nerve is traced deep and all surrounding muscle released. It is similarly traced up toward the scalp again removing muscle as well as a fascial release along the nuchal ridge.

The greater occipital nerve is a big nerve whose course through the muscle and fascia gives it plenty of opportunity to be compressed or squeezed by the surrounding tissues. Its surgical decompression is associated with no adverse sequalae other than how effective it is in creating symptom relief. In my migraine surgery experience the vast majority of carefully selected occipital neuralgia patients get improvement in their symptoms, often substantially so.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshops – Posterior Temporal Implant for Head Widening

Sunday, May 14th, 2017

The side of the head is typically seen or described as the area above the ears. It is influenced by a variety of constituent anatomic structures including bone, muscle and skin. Their thicknesses and the ratio of tissue proportions between them all contribute to the flatness or convexity of the side of the head. The side of the head can anatomically be described as the posterior temporal region since this is where the posterior belly of the temporalis muscle runs up over the convex skull shape (temporal and parietal bones) underneath it.

Aesthetic concerns about the shape of the side of the head do exist and I have seen patients feel that either it is too flat (not enough convexity) or is too full or wide. (too much convexity) In cases of a desire for greater width or fullness to the side of the head, the method of augmentation is with a custom posterior temporal implant. (side of the head implant).

Placed either under the fascia on top of the muscle or in a completely submuscular position, the posterior temporal implant can increase the convexity or width of the side of the head above the ears as seen in the frontal view. The typical implant thickness is in the range of 3 to 7mms. When you add up both sides that could be a change of 6 to 15mms. The incisional access for placement of posterior temporal implant is either from a small vertical incision in the temporal scalp above the ear or from an incision behind the ear in the postauricular skin crease. The incision choice is based on implant size and thickness as well as the hairstyle of the patient. The point of incisional access determines whether the implant is placed on either top of the muscle or underneath 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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