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Dr. Barry Eppley

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Archive for the ‘OR snapshots’ Category

OR Snapshots – Microtia Rib Graft Ear Reconstruction

Friday, December 23rd, 2016


The ear is composed of two basic structures, cartilage and skin. The cartilage component of the ear is considerable as only the earlobe is not supported by it. The cartilage is solely responsible for the very complex shape of the ear with its many hills, valleys, ridges and curves that are seen externally. How it gets this shape is an embryological marvel as six hillocks fuse in utero to ultimately create what we see as the external ear.

While cartilage supports all the convexities and concavities of the ear, its most important contribution is to its elevations or convexities. (helical rim, superior and inferior crus, antihelix, tragus and antitragus) Cartilage can be removed from any of the concave areas and the shape of the ear would not change. This is well known from the common harvesting of ear cartilage in rhinoplasty from the concha, the largest ear concavity which looks the same both before and after graft harvest.

rib-graft-microtia-ear-reconstruction-dr-barry-eppley-indianapoliosThe greatest illustration of the role of cartilage in the shape of the ear is in microtia reconstruction. For children born with parts or all of the external ear missing, the traditional ear reconstruction method is done with rib cartilage. Portions of ribs 6, 7, and 8 are used to create a cartilage ear framework for insertion under the skin. In making his ear framework the complete concept of the ‘hills and valleys’ of the ear must be artistically created by carving and assembling the pieces of rib cartilage. The eventual shape of the ear is seen many months after surgery as the overlying skin shrinks into and around its cartilage shape.

Of all the shaping procedures that are done in plastic surgery throughout the body, making an ear out of rib cartilage in microtia reconstruction certainly qualifies as a sculpting surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Browlift Temporal Implants

Monday, December 19th, 2016


Temporal augmentation has become a popular facial area of augmentation due to injectable fillers and fat. While these injectable methods offer a non-surgical treatment method, their volume retention and smoothness of contour is far from assured.

Temporal implants offer a facial augmentation method that is both permanent and straightforward to place. It is an implant unlike other facial implants as it is intended to augment muscle and not bone. As a result, the implant is very soft and flexible, feeling very much of the consistency of muscle. Another key element to its success is that the implant is placed in the subfascial position and at the subcutaneous level. Sitting on top of the muscle and under the fascia avoids any visible outline of the implant which would occur with eventual soft tissue contraction around the implant had it been placed just under the skin.

temporal-implant-placement-through-browlift-incision-dr-barry-eppley-indianapolisTo place temporal implants under the temporalis fascia, the typical approach is a small vertical incision placed back in the temporal hair. This allows easy access to the deep temporalis fascia which is entered through an additional incision in it. But there are other access incisions through which these implants can be placed. One of these is a hairline incision which is commonly used in browlift surgery. Coming from above, an incision in the temporalis fascia is made superiorly through which the implant pocket is developed and the implant placed.

Temporal implants can be used in conjunction with a browlift for a more complete forehead and temporal rejuvenation. The incision for the browlift provides direct access to the subfascial temporal pocket.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Surgery

Sunday, December 18th, 2016


Rib removal is an effective surgery for anatomic waistline reduction. It is reserved for those women who have tried every other non-surgical and surgical method to narrow their waistlines and are seeking the last resort to do so. It is clearly for the most motivated of women who are willing to accept small back scars to do so.

Removal of the lower ribs does work to narrow the waistline by eliminating some structural support that helps hold the wasitline out. The lowermost two ribs, #s 11 and 12, are called the floating ribs because they are attached only to the vertebrae and not to the sternum or cartilage of the sternum. These ribs taper down to a cartilaginous tip where soft tissues attach. The floating ribs are often called small and delicate but they are not really either. Having taken out many of them they are much longer and stouter than one would think or diagrams show.

rib-removal-12-angulation-dr-barry-eppley-indianapolisWhat is interesting about the free floating ribs is their orientation to the rest of the ribcage. If one looks carefully at a diagram or skeletal representation, it becomes apparent how much of a downward angulation they have. They are oriented more than 60 degrees at a downward angle which is always impressive when they are exposed surgically.

Seeing their downward angulation during surgery allows for an appreciation of why it works for anatomic waistline narrowing. They do go as far down as almost the iliac crest which provides some support to the width of the waistline. It is also clear why some people may complain that they feel their ribs touch their hip bones when they bend to the side…because they in fact do.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Brow Bone Reduction by Burring

Sunday, December 18th, 2016


Brow bone reduction is useful for both men and women who have frontal sinus development that creates an unaesthetic appearance. It is far more commonly done in men whether it be for reduction of very prominent brow bone protrusions or as part of an overall facial feminization surgery for male to female transgender patients.

In most of these types of brow bone reductions a significant change is needed and this requires an osteoplastic setback technique. This is where the complete outer table of bone over the frontal sinus air cavity is removed, reshaped and put back in a more recessed position.

But brow bone reduction can also be done by a burring technique albeit for a more limited result. This is where a hand piece and rotary burr are used to shave down the bone as much as possible but without actually going through the bone into the sinus. The amount of reduction possible is controlled by the thickness of the outer table of bone overlying the sinus. This is relevant over the inner half of the brow bones as this is where the frontal sinus lies. Over the outer half or tail of the brow bones one can burr away as it is solid bone.

brow-bone-reduction-burring-techniquie-dr-barry-eppley-indianapolisBrow brow reduction by burring has the advantage that it can be done through more limited access. An incisional approach such as a pretrichial or hairline browlift provides good linear access for the instrumentation to reach the brow bones from side to side. It also allows adequate visualization of the supraorbital nerves so they are not injured during the bone reduction.

Brow bone reduction by burring works best in those men that just want a little taken off the brow bones or for women who have developed a small brow bone prominence and want it reduced.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Septal Graft Dorsal Augmentation Rhinoplasty

Saturday, December 17th, 2016


Augmentation of the nose can be successfully done by a variety of materials. While each  autologous and alloplastic material has their own advantages and disadvantages, one’s own cartilage will always have the superior biologic edge. While cartilage is from one’s own body and is well accepted like all other autologous grafts, it has the unique property of being relatively inert. A cartilage graft put in today will look the same when seen years later. (which is very much unlike most other autologous grafts)

The need for cartilage grafts in rhinoplasty is greatest when dorsal augmentation is needed. Significant dorsal augmentation requires substantial cartilage graft material. Of the three sources of cartilage graft harvest, only the septum offers an assured straightness which is of paramount importance in dorsal augmentation rhinoplasty.

rib-graft-rhinoplasty-intraop-dr-barry-eppley-indianapolisThe septum can be a rich source of graft material when it is primarily harvested. It is usually of adequate length in many patients and can be layered to create 3 to 4mms of dorsal height by so doing. This is usually more than adequate to meet the needs of some primary and most revisional rhinoplasty surgeries.

But once the septum has been harvested it is no longer of any value for dorsal augmentation. When really significant amounts of dorsal augmentation are need, such as in Asian and African-American rhinoplasties, an autologous dorsal augmentation will usually require a rib graft harvest.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Subfascial Temporal Implants

Wednesday, December 14th, 2016


Augmentation of the temporal region of the face has become popularized through the use of injectable synthetic fillers and fat. While such injectable treatments can be successful, they can be plagued by unpredictability of volume retention and the need for ongoing treatments.

Like it is anywhere else on the face where aesthetic bone augmentation is desired, implants offer a permanent solution to the volume retention issue as well as that of the smoothness of the augmented contours. But the temporal region is not a bony support region and has historically not been treated by implant augmentation methods.

Temporal implants are the newest type of facial implants and have been successful for several different reasons. One reason has been the low durometer of the silicone used in temporal implants. This makes them feel more like muscle than bone which is important in a soft tissue region of the temples. That physical feature also makes them able to be inserted through incisions that are smaller than the diameter measurements of the implant.

subfascial-temporal-implant-intraop-dr-barry-eppley-indianapolisBut the single greatest reason for the current success of temporal implants is that they are placed in the subfascial and not the subcutaneous location. By placing them under the tenporalis fascia and on top of the muscle, a safe and easy dissection plane is used that avoids the frontal branch of the facial nerve. The cover of the thick fascia on top of the implant obscures any outline of the implant that would occur after tissue contraction has occurred.

Temporal implants are unique amongst facial implants since this is not a bone augmentation site. This is a muscle augmentation site since muscle is what principally comprises the temporal fossa. The feel of the implant and its location should reflect what it is intended to augment.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Forehead Augmentation with Hydroxyapatite Cement

Monday, December 12th, 2016

The forehead occupies a third of the visible face. Because it does not have any topographic features that draw one’s attention to it like other parts of the face, its broad non-remarkable surface is not an immediate eye-catcher. But despite being relatively bland, the sheer size of the forehead does play a role in aesthetics and there are well known gender differences in its shape.

The male forehead has the topographic feature of brow bones with a forehead that is flatter and may even have a slight backward slope to it. Conversely women usually have no visible brow bones and a more convex and rounded forehead that is almost completely vertical.

For women that desire forehead augmentation there are a variety of material options to achieve a feminization effect. From bone cements to preformed implants each choice has their own unique advantages and disadvantages. To some degree they are all implant materials and the body responds to them by differing degrees of encapsulation.

hydroxyapatite-cement-forehead-augmentation-dr-barry-eppley-indianapolisFrom a biologic standpoint the argument could be made that hydroxyapatite cement is the most biocompatible material for forehead augmentation. A direct bonding of the material does occur without a fibrous layer at the bone-cement interface. This unique biologic response to it is countered by the need to apply the cement in an open fashion through a coronal scalp incision. It is also the most costly of all forehead augmentation material options.

While there are different forms of commercially available hydroxypatite cement for craniofacial applications, these difference are largely in the material’s handling and set properties.

OR Snapshots – Rib Removals in Waistline Slimming

Friday, December 9th, 2016


Rib removal is most commonly known for its effect on helping reduce the anatomic waistline or waistline slimming . Usually the ribs that are partially removed (outer halves) are #s 11 and 12. This is because these are the true free floaters and are pointed 45 to 60 degrees straight downward. Once one realizes the true orientation of these two ribs compared to all of the ribs above them, it is easy to understand why they would be effective in helping to narrow the anatomic waistline.

Rib #10, like #11 and #12, are part of the five false ribs but differ from the two below them. It is oriented slightly more horizontal and wraps around the waistline to a cartilaginous connection to the rib above it. This still makes its management useful in anatomic waistline reduction but just not as much as the lower two free floater ribs.

rib-removal-for-waistline-reduction-dr-barry-eppley-indianapolisBecause of the curvature and longer length of rib #10, it is harder (albeit not impossible) to remove from the typical small back incision used for the lower rib removals. An alternative strategy that I have developed is the ‘rib arc reduction’ technique. Rather than removing the outer half of the rib, a smaller section is taken out of its curvature in the middle. This allows the arc of the rib to be reduced as it collapses, like removing the central part of a spanning bridge. This keeps most of the rib in place but it has lost some of its outward support thus playing a role in waistline slimming. In looking at an intraoperative picture of rib removals this is why one can see just a small portion of rib #10 that has been removed.

Rib removal for waistline slimming uses two basic approaches to the ribcage, subtotal outer half rib removal and rib arch reduction techniques. These are different than how many people perceive rib removal as the complete removal of the rib which just not how it is done.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Jawline Implant Placement

Monday, December 5th, 2016


The use of a custom jawline implant is the most effective technique to reshaping the lower face. Its one-piece design allows the changes in the front of the jaw (chin) and the back of the jaw (jaw angles) to be connected in a smooth linear fashion.

While the one-piece design of the implant has numerous aesthetic advantages, it does pose a unique intraoperative challenge. How does such a jawline implant get inserted? The sheer size of the implant is completely different than much smaller chin and jaw angle implants which are placed through single incisions.

The custom jawline implant is usually placed through a three incisional approach. There is the two intraoral posterior vestibular incisions and the anterior chin incision. The chin incision can be done either through the skin under the chin or from inside the mouth. Through these three incisions a subperiosteal tunnel is made that connects them going under the exit of the mental nerve from the bone. The custom jawline implant is positioned into place by passing the back parts of the implant through the chin incision

The size of the jaw angle part of the implant determines how easy or hard the custom jawline implant placement technique is. If the jaw angle implant part is very large it may be impossible to pass it under the tunnel that connects the chin and the jaw angle without significant risk of injuring or even tearing the mental nerve.

bg-custom-jawline-implant-reunited-in-midlineIn these cases the custom jawline implant is split in the middle and each half passed from back to front. Since the chin segment is smaller it passes easier through the subcutaneous tunnel and poses less risk of injury to the mental nerve. The implant halves are then reunited in the midline using either sutures or screws.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Scrotal Enlargement by Fat Injections

Monday, November 28th, 2016


There are numerous options for elective plastic surgery of the male genital region. Various penile lengthening and enlargement procedures, testicular implants and scrotal lifts are all options for the man who seeks penoscrotal enhancements.

The size of the scrotum is largely determined by what lies within. The size of the testicles is largely responsible for the scrotal sac size. But the size of the testicles can not be increased naturally through hormone supplementation or other non-surgical methods. There is the concept of wrapping a shelled out testicular implant around the existing testicle to increase its overall size as one surgical option.

scrotal-enlargement-by-fat-injections-dr-barry-eppley-indianapolisThe other surgical option for scrotal enlargement are fat injections. Just like fat injections are used all over the body for soft tissue augmentation, they can be safely inject intothe scrotum as well. The scrotum is not known as a large repository of fat but it does have fat amongst its various tissue layers.

Given its relatively small body size and the low volume of fat that need to be injected, fat survival in the scrotum would be expected to be high. Using blunt cannulas and low pressure injection, fat can be safely placed through the scrotum without injury to testicles or the vas deferens.

Besides scrotal enlargement, one other invaluable use of fat injections to the scrotum would be in preparation for testicular implant placement when one has had prior irradiation. Fat injected into tissues that have been irradiated is well known to improve its vascularity and make it more amenable to surgical manipulation with a lowered risk of healing and infectious complications.

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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