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Archive for the ‘plastic surgery case study’ Category

Case Study – Multiple Lipoma Excisions in Familial Lipomatosis

Saturday, August 19th, 2017


Background: Familial multiple lipomatosis (FLM) is a well known condition that is associated with the lifelong development of lipomatous tumors. These lipomas occur almost exclusively on the trunk and extremities with the head, neck and shoulders usually being spared. It has been identified as an autosomal dominant condition that has been associated with chromosome 12q15.

The typical lipoma has a surrounding capsule and appears as a solitary lesion of various sizes. But the lipomas that occur in FLM are multiple, are often in clusters or a chain and have been described as more rubbery in feel. While most are asymptomatic, their location and size often make them painful.

The surgical treatment of the lipomas in FLM is excision. These excisions are usually done periodically throughout the patient’s life based on those that are associated with pain or significant cosmetic deformity. While the excisions may cure those that are removed, new lipomas will likely develop in contiguous locations in the future.

Case Study: This 60 year-old male with known FLM presented for a more comprehensive approach to his lipoma excisions. He had been through multiple lipoma excisions up to this point in life but were always limited to a handful at a time.

Under general anesthesia, 85 lesions sites of the upper arms, stomach and thighs were treated through an ‘expressive excision’ technique. This is where the skin incision is relatively small through which blunt undermining around the lipoma(s) is done. Then manual pressure is applied to basically squeeze the lipomas out through the small incision. With this method over 235 lipomas were removed over a three hour operation.

While a comprehensive approach to multiple lipomas requires a lot of incisions and resultant scars, the expressive excision technique keeps the length of each incision relatively small with a very low risk of infection or bleeding.


  1. Familial lipomatosis creates the need for recurrent excisions of symptomatic lipomas throughout the patient’s life.
  2. In removing large numbers of lipomas an ‘expressive excision’ technique is the most efficient method.
  3. While excision is not a cure for FLM lipomas, single session large number removals can provide long periods of symptom relief.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Teenage Male Cleft Rhinoplasty

Friday, August 11th, 2017


Background: Of all the difficult cases in rhinoplasty surgery, the cleft  nose remains one of the most challenging. While this challenge is magnified in the bilateral cleft nose, it is only slightly less in the unilateral cleft lip and palate patient. The challenge its not in understanding the deformity but working with nasal tissues that are both deformed and often congenitally deficient.

While the cleft nasal cartilages are deformed due to the asymmetry caused by the cleft that runs up through its nasal floor, the overlying skin also poses limitations. The affected nasal alar rim is always pulled down and the skin is often restricted by a recessed nasal base. Equally importantly the internal vestibular tissues usually have a web that is both limiting in elevation and for which a satisfactory solution remains elusive.

While many cleft patients undergo limited nasal reshaping procedures as an infant or child,  the more formal septorhinoplasty awaits until after puberty. When that should be done can be debated but it is most accepted that it awaits until after any jaw surgery may be done or the determination made that it is not needed. A stable maxillary base that will  to change in the future is a prerequisite for rhinoplasty surgery.

Case Study: This teenage left cleft lip and palpate male has been through all of his primary cleft lip and palate repairs as well as secondary alveolar bone grafting. He had also had a tip rhinoplasty as a child as well.

Under general anesthesia, an open seiptorhinoplasty was performed. Septal cartilage was used for a columellar strut, left middle vault spreader graft and left alar batten graft. Bilateral subtotal inferior turbinectomies were also done.

In a cleft rhinoplasty some of the most important goals are to improve the shape of the nasal tip and cleft-sided nostril deformity. To do so requires septal correction and in the process the harvest of cartilage grafts to provide the structural rigidity that is needed to do so.


  1. The cleft nasal deformity is a combination of structural deformity and structural deficiency.
  2. Cleft septorhinioplasties almost always needs to be done with an open approach and usually requires cartilage grafting as well.
  3. The nasal tip deformity in the cleft nose can never be normalized completely but it can have major improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Lifting Effect of Breast Implants

Wednesday, August 9th, 2017


Background: Many women who present for breast augmentation have varying degrees of breast ptosis or sagging. Some have the belief that a breast implant has the capability to lift the sagging breast and avoid the need for some type of breast lift. Unfortunately this is almost never the case much to the chagrin of the patient.

Burt there are cases where with right size off breast implant and with a breast sag that is not too severe that a breast augmentation procedure by itself can lift up a sagging breast. The key is the type of breast sag. As breast ptosis is defined as the position of the nipple relative to the breast (inframmammary) fold, a breast sag where the nipple is just at the level of the fold is a preoperative sign that an implant alone will suffice.

Case Study: This 38 year-old female presented for breast augmentation. She had small breasts but had lost most of her breast volume after having children.

Under general anesthesia, an inframammary incisional approach was used to place 400cc high profile silicone breast implants in a dual plane position. As judged by her after surgery side view picture comparisons of her elevated nipple position caused by the breast mound enlargement.

Nipple positions at or above the level of the inframmary fold will be elevated from the placement of breast implants. This will occur even when the implant is placed in the submuscular position. The size of the breast implant also plays a role with ‘larger’ implants being more effective than smaller ones. To some degree there is the effect of the ratio of implant to natural breast mound tissue. The greater this ratio the more effective the lift will be.

In some cases when the implant to natural mound tissue is more even, the initially uplifted breast tissue can ‘fall off’ of the implant over time. This is because the weight of the breast tissue is not well supported by the implant size. This is not the case int this example but can be in more marginal patients who are better off having a lift with the implant placement.


  1. Breast implants do not have a great ability to lift up a sagging breast.
  2. A good size implant in the properly selected patient can have some breast lifting effect.
  3. Over time the augmented ‘breast lifted’ patient may have some glandular tissue slide off the implant due to gravity and tissue stretch.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Buffalo Hump Reduction

Thursday, August 3rd, 2017


Background: The buffalo hump is a descriptive term that universally applies to a discrete collection of fat on the back of the neck. Looking at the American bison it is easy to see why it has its name with the massive shoulders of the animal being amongst its most distinct features. But unlike the bison, the human buffalo hump is not muscle but fat.

The dorsocervical collection of fat in humans both unusual and distinct for two reasons. First, it is not a typical location for fat to deposit as it is not known for being a metabolic depot site. It may reflect the congenital location of brown fat which is known to be present in newborns but diminishes with age. Secondly what activates the enlargement of the dorsocervical fat pad is not precisely known. Certain medications and illnesses are associated with its development but it can also occur in people who do have these drug or disease associations.

Case Study: This 22 year-old male presented for treatment for his large buffalo hump deformity. He was a large adult man (almost 300lbs) but he did not have any of the associated triggers for its development. It caused him neck pain and restricted his neck extension. He was also socially embarrassed by it.

Under general anesthesia and in the prone position,  a three-hole liposuction approach was used. Using power-assisted liposuction with baskets as well as smooth round-tipped cannulas the very dense fibrofatty tissue was aggressively treated with an aspirate volume of just under one liter. (900ccs)

His immediate result during surgery showed the degree of improvement which largely made the back of his neck flat again. Unfortunately there are no good methods of after surgery compression for the back of his neck so he will have considerable swelling which will take more than a month to return to this intreoperative result.

The traditional method of buffalo hump reduction was open excision. Due to its very dense fibrofatty tissue it was felt that liposuction could not get an adequate reduction. And if one was using traditional ‘elbow-driven’ liposuction this would still hold true. But today’s many power-driven liposuction technologies make it possible to reduce denser and more fibrous fatty areas like the buffalo hump. While not every case has such dense fibrous fat many buffalo humps do.


  1. The buffalo hump deformity is an abnormal development of fat in the dorsocervical fad pad.
  2. It is a often a dense fibrofatty tissue that requires a mechanized or energy-driven liposuction method for removal.
  3. An open excision of the buffalo hump can usually be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Linear Custom Jawline Implant

Wednesday, August 2nd, 2017


Background: Augmentation of the total lower third of the face is historically and most commonly done using standard implants. The combination of chin and jaw angle implants, a three implant approach, provides enhancement of the three corners of the lower face. While theoretically appealing and a good solution for many jawline needs, it can be unsuccessful for a variety of reasons. These include implant asymmetry, the inability of standard implants to provide the desired aesthetic result and the lack of connection between all three implants.

A custom jawline implant connects the chin and jaw angle regions in either a linear or non-linear fashion.The size or thickness of the connection between the chin and jaw angles of the implant determines whether there is a smooth or linear look going from the chin back to the jaw angles or whether the chin and jaw angles stand out more than what connects between them. (non-linear look)

Designing a custom jawline implant with existing indwelling implants is ‘easier’ and more helpful than if no implants were there at all. Knowing what the aesthetic effects of existing implants creates, even if undesired, helps guide a new implant design that may produce a better result. While the custom implant design process is greater from the standpoint of fit to the bone, symmetry of both sides of the implant and creating a unified look, the computer or surgeon has no way of knowing exactly what implant dimensions can exactly achieve the patient’s goals.

Case Study: This 45 year-old male had Medpor chin and jaw angle implants previously placed which did not produce the jawline look that he had hoped. Fundamentally it did not give the jawline angularity that he seemed and did not have a smooth connection between the chin and the jaw angles. In the implant design process his existing implants were digitally removed and a one-piece jawline implant designed.

Under general anesthesia and through a combined intraoral and submental existing incisions, his Medpor chin and jaw angle implants and their numerous large screws were removed.

His new custom jawline implant was placed using a split implant technique. Due to the size of the implant jaw angles and concerns about injury to the mental nerve when passing the implant from front to back as a single piece, the implant is first sectioned in the midline of the chin in a geometric interlocking pattern. This then permits the implant to be placed in two sections from back to front and then reconnected in the middle. This is safer for the mental nerve as the sizes of the implant that must pass underneath it is smaller.

His one day results show an immediate improvement in his jawline shape in a more connected fashion. (linear jawline look) There is also more angularity evident in the chin and jaw angle corners. While he will go on to have some tremendous swelling that will take up to month or more to fully resolve, his very early jawline result looks more favorable to his aesthetic goals.

1) Jawline augmentation by three separate preformed implants often does produce a satisfactory or desired shape of the lower third of the face.
2) With existing chin and jaw angle implants in place, a custom jawline implant can be designed for an improved facial outcome.
3) Contrary to popular perception, Medpor implants can be successfully removed although it is more traumatic to the tissues than that of silicone implant removal.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Vertical Breast Lifts with Implants

Monday, July 31st, 2017


Background: The sagging of the female breast is a common sequelae to age, pregnancies and weight loss. The shape of a woman’s breast is rarely a static structure over their lifetime being subject to a variety of forces that work to make the breast mound lose its shape. Stretching of the mound skin and loss of breast volume are the anatomic reasons for ‘the breasts heading south’.

Correction of breast sagging, therefore, necessitates addressing the loose skin and lack of adequate volume. Various types of breast lifts combined with a large range of breast implant sizes creates options for rejuvenating the sagging breast mound.

The use of a combination breast lift and implant placement is a common breast reshaping procedure. But mixing the type of breast lift and the size of implant defies an exact scientific method to do so and not every women can get any breast implant size with their lift that they desire.

Case Study: This 34 year-old female had developed significant sagging and loss of breast volume after four pregnancies. She needed as much of a breast lift as she did that of more breast volume.

Under general anesthesia, she underwent a combined vertical breast lift with the placement of 400cc silicone breast implants. Her results shows that the size of the breast lift chosen can dictate how much of a breast lift result can be obtained.

In the combined breast lift and implant surgery, also known as an implant mastopexy, the effects of the two procedures often are at a conflict. Since a breast lift achieves its effect to some degree by skin removal and tightening and an implant exerts its effect by skin expansion, it is easy to see how combining these procedures often creates the need for compromise. For more of an uplifted and perky breast, a smaller implant must often be chosen. For larger implant volumes the amount of lifting effect will often not be as great.

1) Breasts lifts are often done at the same time as the placement of breast implants in certain amounts of breast sagging.
2) Large amounts of breast sagging or the desire for large breast implants may necessitate a staged approach to lifting and implant placement.
3) The use of breast implants in the sagging breasts may often be to just maintain upper pole fullness.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Female Custom V-Line Jaw Implants

Sunday, July 23rd, 2017


Background: The shape of the jawline has taken on great aesthetic importance in contemporary society. This is not just for men but for females as well. But the desired shape of the female jawline is different from that of men. It is desirous to be more tapered from back to front and have more of a triangular or V-shape. While some women have this jaw shape naturally, most do not.

The well known V-line jaw surgery comes from Asia where it is commonly done. The Asian face often has a bigger lower jaw with larger jaw angles as part of an overall wider and flatter facial shape. Dramatic reductions in the jawline through amputation of the jaw angles and jawline combined with a T-shaped chin reduction creates the V-line effect.

But in many Caucasian faces such reductions of the jaw will not produce the same reshaping effect or can not be done with a smaller jaw size. The opposite approach, augmentation of the jawline, may be needed to create a V-line effect.

Case Study: This 26 year-old female wanted to have a more tapered jawline look. She had a prior chin implant placed but it did not create the desired effect. Her 3D CT scan showed a chin implant sitting high on the chin bone  way above the edge of the chin bone. She also had high jaw angles.

Her 3D CT scan was used to make vertical lengthening jaw angle implants (with minimal width) and a v-shaped chin implant that created a completely central augmentation.

Under general anesthesia, her chin implant was initially removed and replaced through a submental incisional approach. This was to ensure that the implants sat down on the bone as low as it was designed and to place screw fixation. The jaw angle implants were placed through an intraoral approach using posterior vestibular mucosal incisions. Because it was a vertical lengthening implant, where half of the implant sits off the bone, double screw fixation was used.

A more tapered and shaped jawline is not always obtained by bone reduction. In some non-Asian jaws augmentation of the jaw angle and chin points may suffice.


  1. V-line jaw reshaping is classically done by chin and jaw angle bine reduction/reshaping.
  2. In the Caucasian face augmentation of the chin and jaw angles may be needed to create the V-line effect.
  3. Custom chin and jaw angle implants can be designed to create a more tapered jawline shape.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Full Tummy Tuck and Flank Liposuction Before Weight Loss

Sunday, July 23rd, 2017


Background: The tummy tuck is one of the most commonly performed procedures in body contouring surgery. It is used in a wide range of body types that have developed excessive abdominal skin and fat. As a result the procedure can be modified in many ways to suit the patient’s tissue removal needs. How long the tummy tuck incision needs to be and whether liposuction is performed as part of the same procedure are always the two main considerations.\

Another important consideration is what should the patient’s weight be at the time of the procedure. Many patients seek a tummy tuck that are more than their ideal body weight. They may want to lose weight before having surgery and may even have a target weight in mind. Others say they can not lose any more weight and need the surgery to get them ‘jumpstarted’ on their weight loss.

While a tummy tuck and/or liposuction should never be thought of as a weight loss procedure, it obviously will cause some amount of weight loss afterwards due to tissue removal and the catabolic effects of the surgical trauma. It is a good general rule that patients should be within 10 to 15 lbs of their goal weight before having body contouring surgery to get the best resuilts.

Case Study: This 28 year-old female had always been overweight but became more so having several children. Despite her best efforts she was unable to get close to her ideal body weight and had the body type that was never going to get close anyway.

Under general anesthesia, she underwent a full tummy tuck with umbilical transposition. Liposuction was done on the upper abdomen and out into the flanks removing 1,800ccs of aspirate. Her six week after results showed major improvement with the elimination of any tissue overhang and the noticeable improvement in her waistline. Her scars remained red as expected at this early point after surgery and will take another six months to maximally fade.

While tummy tucks should ideally be performed when someone is close to their ideal body weight or weight loss goal, this is not always possible. Some people just don’t have the body type attain an ideal weight and others can not always make the commitment needed to do it even if it were possible. While the result may not always be as good than if the patient’s weight was lower, noticeable improvements will be seen. The favorable change may provide some additional incentive for the patient to see how much better they can now due on their own.


  1. A tummy tuck can be performed in anyone that has excessive abdominal skin and fat. But the lower one’s weight at the time of the surgery the better the result will be.
  2. Most full tummy tucks in larger abdomens will require liposuction into the flanks along the sides for better contouring.
  3. The maturation of tummy tuck scars can take up to six months or longer.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Secondary Custom Skull Implant Replacement

Friday, July 21st, 2017


Background: Various forms of skull augmentation have become a common procedure in my practice. From flatness on the back of the head, a narrow head width, the desire for greater skull height and shape to a more projecting forehead and/or brows, custom skull implants can more than adequately meet these needs with a safe and fairly predictable outcome.

Such skull implants are very powerful but their amount of augmentation possible its ultimately controlled by the stretch of the scalp. Because of some patient desires for results that exceed what the scalp will allow, the concept of a two-stage skull augmentation was developed. In the first stage a scalp tissue expander is placed which creates the subperiosteal pocket space needed for the placement of a large custom skull implant as the second stage.

With one and two stage custom skull augmentations, the patient must traditionally decide up front which direction they want to go based on their aesthetic head shape goals. If a patient knows that they really want a larger type result they may opt for the standard two stage approach upon front. But some patients who may be uncertain or for economic or logistical reasons go instead for the immediate placement of the implant. But what if one does so and then they decide later they want a larger skull augmentation?

Case Study: This 28 year-old male has a prior custom skull implant placed one year previously. Since it as an immediate insertion of an implant the thickness over the crown of the skull was 8mms. While he was content with its size at that time he now desired to have even more augmentation. He has a very well healed semi-coronal scalp incision.

A new custom skull implant was designed that increased the thickness over the crown out to 14mm, an effective increase of 70% over his original implant size and volume.

Under general anesthesia, his existing coronal incision was re-opened and his skull implant exposed and removed. The difference in the height of the two implants could be seen when placed side by side. The new implant was inserted after the creation of multiple perfusion holes and the scalp incision closed with minimal tension over it.

This is not the first time that I have performed a secondary larger skull implant to replace an existing one. In each case, as this patient demonstrates, the first skull implant does act as an effective tissue expander. There is more stretch of the scalp to be had even though the initial implant has a capsule around it. This is a relevant observation for those patients who may ideally want a much larger skull implant but are limited at the time for a variety of reasons to a one-stage skull augmentation approach.


  1. Like any other form of body enhancement patients may want to increase the size of their augmentation later.
  2. A larger skull implant can be placed secondarily after a first one which acts as a ‘first stage’ tissue expander.
  3. The scalp expansion effect of a first skull implant generally allows for a 50% or greater in volume for the second skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Forehead-Temporal Implant Replacement

Wednesday, July 19th, 2017


Background: The size of the forehead has a major influence on the appearance of one’s face, occupying the entire upper third of it. Beyond its size the shape of the forehead is also important with many gender specific features. In general, males have stronger brows, a wider forehead and a gentle backward slope to it. In contrast female have no brow bone protrusion, a convex forehead shape that has a more vertical orientation.

\Of all the facial bones, the forehead is the least commonly augmented. Intraoperatively shaped bone cements and preoperatively shaped custom implants are the two most common methods of forehead augmentation. Given the advantages of a more thought out forehead shape design and the ability to place it through a small scalp incision, custom forehead implants are usually the superior treatment approach.

But the success of a custom forehead implants comes down to its design. While computer designing an implant has many advantages, what the best shape and dimensions are that can create the patient’s desired forehead shape  is not a mathematical calculation. It is an art form that is based on the surgeon’s understanding of the patient’s desires and experience in appreciating the effects of various designs on the outward aesthetic outcome.

Case Study: This 25 year-old male had a custom PMMA forehead implant placed through a full coronal scalp incision six months previously. While the implant provided some brow bone augmentative effect, it did not extend all the way top the forehead and created a line of demarcation at the mid-forehead level. He was interested in having an implant design that covered his entire forehead as well as extended outward further into the temporal areas.

A new custom forehead-temporal implant design was made that covered more than 100% greater surface area than his indwelling implant. It covered the entire forehead back behind the frontal hairline, extended over the entire anterior temporal region down to the zygomatic arches as well as added a few more millimeters of brow bone augmentation.

Under general anesthesia, his existing coronal incision was re-opened and his forehead implant exposed and removed. The difference in surface area coverage between the removed and new custom forehead-temporal implant was significant.

The new style of custom forehead implant was then inserted and secured with small microscrews to the bone and sutures of the temporal extensions to the temporal fascia.

When designing a forehead implant there are four surface areas or zones to consider. They are the brow bones, the mid- and upper forehead, the temporal lines and the temporal zones. (often referred to as the sides of the forehead) The coverage or lack oil coverage of these areas must first be considered before determining what thicknesses they should be.


  1. Subtotal forehead implants often leave the forehead inadequately augmented.
  2. Custom forehead implants must consider the impact on the entire forehead as well as the adding temporal regions.
  3. Complete frontal augmentation covers the entire forehead as well as the temporal areas.

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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