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Facial Skeletal Changes with Aging

Sunday, September 3rd, 2017

 

The anatomic structure of the face is well known to change with aging from the outer skin down to the bone. This recognition of how the face ages provides for more effective treatment strategies. While once skin pulling and tightening was the only treatment approach, the understanding of the loss of fat with aging has led to the addition of fat grafting as part of anti-aging facial surgery.

In the August 2017 issue of the JAMA Facial Plastic Surgery Journal an article was published entitled ‘Patterns of Change in Facial Skeletal Aging’. In this paper the authors studied CT scans of over a dozen adult faces (ages 40 to 55) who had such studies done at least eight years apart that included the skull down through the midface. Measurements were made using landmarks on 2D scans as well as 3D reconstructions. Specifically, glabellar and maxillary angles as well as pyriform height and width were studied.Their results showed significant decreases in glabellar angles (- 2 degrees on average) and maxillary angles. (around 2 degrees on average) There were increases in pyriform width and height as well.

While the bony changes with aging has been studied before, this study is relevant because it assessed the same patients over different time periods. Opening up of the glabellar and maxillary angles as well and increases in pyriform height and width are signs of bone loss/atrophy. Such midface changes can be more severely affected with the loss of teeth although this was not specifically evaluated in this study. (I assume their patients had a reasonably intact maxillary dentition)

The real relevance of this study is whether some patients may benefit by bony augmentation as part of their anti-aging facial surgery. Specifically midface augmentation of the premaxillary-paranasal region may be considered. This could be especially helpful for the patient with deep nasolabial folds and a recessed nasal base.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Massive Palatal Tori Removals

Sunday, September 3rd, 2017

 

Background: The finding of a bony growth on the palate is most commonly the result of the development of a tori. They typically present as a small midline bony lesion less than a few centimeters in size in early adult life. They are capable of growth over one’s lifetime but it its usually very slow.

Palatal tori are very common and are estimated to occur in 10% to 20% of the general population. They are more prevalent in some ethnic populations but are also more often seen in females. It is not known why they occur but they can be inherited and have been claimed to be an autosomal dominant trait.

Palatal tori occur in different patterns and are classified based on their shape. They can occur as flat, spindle, nodular and lobular types. Nodular and lobular tori are usually bigger in size. Palatal tori are benign bony outcroppings that do not usually need removal unless they are a source of irritation or are an obstruction to the fit of dentures.

Case Study: This middle-aged female had large palatal for her entire life. She had a family history of her mother having large palatal tori as well. They occasionally became sore but she never considered removing them until she needed partial dentures. Her palatal tori consisted of four bony growths, two large smooth ones on the inside of the alveolar ridge at the molar area as well as a midline lobular one that had two large halves. All four tori merged together leaving just a narrow linear gap between them. (a source of food entrapment)

Under general anesthesia, laterally based mucoperiosteal flaps were used to expose the lateral tori for their reduction by a high speed burr and osteotomes. A t-shaped mucoperiosteal flap was used to exposed the bilobed midline tori for their reduction by a similar bore removal technique..

Massive palatal tori removal requires most of the hard palatal tissues to be elevated for exposure and adequate bone removal.  While effective, complete mucosal healing requires a few weeks and is fairly sore.

Highlights:

  1. Palatal tori are commonly a single midline bony lesion but four in a single patient is very rare.
  2. Removal of palatal tori may be necessary for the fabrication of partial or full dentures.
  3. The removal of palatal tori requires the reflection of full-thickness mucoperiosteal flaps.

OR Snapshots – Lingual Frenuloplasty

Saturday, September 2nd, 2017

 

Being tongue-tied is a common phrase that implies one can not speak due to a loss of words. But being tongue-tied is also a real medical condition that is a well known congenital oral defect known as ankyloglossia. It occurs when the attachment of the tongue (lingual frenulum)) is unnaturally short.

The lingual frenum is a web of mucous membrane that connects the underside of the tongue to the front of the floor of the mouth at the locations of Wharton’s ducts. During fetal development the lingual frenum serves to keep the tongue fixed into position as it grows forward as the oral structures around it form. If some abnormality of the frenum occurs during this process, the frenum remains short and its lack of adequate length is evident at birth. Very short frenulum attachments can cause numerous functional problems with speech, feeding and oral hygiene/function.

Surgical release of short lingual frenum is known as a frenoplasty. There are debates as to when this procedure should be done if needed. But when it is done the technique of doing it remains the same. In infants and children the procedure is done under a limited general anesthetic. The frenum is incised with a needlepoint electrocautery at its tightest point on the underside of the tongue. With the tongue on stretch, the release is performed until the tip of the tongue can be brought well past the incisal edges of the lower teeth. This v-shaped release is then closed as a linear line with an elongated undersurface of the tongue with small resorbable sutures.

The lingual frenuloplasty is an uncomplicated procedure that its highly effective and has a short operative time. Its only potential complications are disruption of the salivary ducts or the lingual veins, both of which are easily avoided.

Dr. Barry Eppley

Indianapolis, Indiana

Real Self 100 2016 Dr Barry Eppley

Tuesday, March 28th, 2017

 

Real Self 2016 Dr Barry Eppley IndianapolisIndianapolis plastic surgeon Dr. Barry Eppley has again recognized as one of 100 doctors worldwide to receive the RealSelf 100 Award, a prestigious award honoring the top influencers on REAL SELF the most trusted online destination to get informed about elective cosmetic procedures and to find and connect with doctors and clinics.

In 2016, more than 82 million people visited RealSelf to research cosmetic treatments and connect with local medical professionals. The RealSelf 100 Award, now in its seventh year, honors the top rated and most engaged board-certified aesthetic doctors who consistently demonstrated a commitment to patient education and positive patient outcomes throughout 2016. This elite group of 100 doctors have excelled at sharing their expertise, free of charge, with tens of millions of RealSelf community members actively searching for information and the right provider, and together contributed 25 percent of the half a million total answers posted on RealSelf in 2016.

“The RealSelf 100 represents an exclusive group of doctors who embody both excellent patient service and an ongoing commitment to educating consumers shopping in the aesthetics market,” said Tom Seery, Founder and CEO of RealSelf. “Our research shows that more than 95 percent of patients expect a practice to engage with them online. These doctors are leading the way in terms of their online engagement and focus on empowering patients with good information.”
RealSelf is the largest online destination to get informed about elective cosmetic procedures and to find the right doctor or clinic. More than 9 million people visit RealSelf each month to find out which treatments and providers live up to their promise of being “Worth It.” RealSelf is powered by unbiased experiences shared by consumers for hundreds of treatments, ranging from simple skincare to highly considered cosmetic surgery. Offering millions of photos and medical expert answers, RealSelf has become the essential resource and service for those seeking to find the right doctor or clinic.

Buffalo Hump Reduction

Friday, September 30th, 2016

 

The buffalo hump neck deformity refers to a collection of fatty collections on the back of the neck. The size of the fat collection can vary greatly from small lipomas to very large hump-shaped fatty tumors. They can appear gradually with no apparent reason or can occur because of well known causes such as HIV lipodystrophy as the most recognized etiology of large buffalo hump deformities.

Appearing on the back of the head, they present as masses that stick out as the name implies. Because of their location they often create discomfort and restriction of neck extension. Their location on the back of the neck determines what type of treatment would be used to treat them.

buffalo-hump-lipoma-removal-dr-barry-eppley-indianapolisBuffalo humps can occur at two different tissue locations. One anatomic location is partial intramuscular. These present as well formed and encapsulated lipomas. They can only be completely removed by an open excision. Their encapsulated form allows for complete removal from their partial intramuscular location.

Buffalo humps can also occur at the subcutaneous level. The native posterior neck subcutaneous fat becomes enlarged. The dysmorphic fat is not necessarily encapsulated like the traditional lipoma. It is more diffuse in nature and is often larger than the encapsulated lipoma. This form of buffalo hump can be treated by liposuction. Its subcutaneous location allows for it to be more easily and effectively removed. While open excision can be performed liposuction is usually the procedure of choice. Because of its more fibrous consistency, energy-driven forms liposuction are preferred.

Dr. Barry Eppley

Indianapolis, Indiana

Tragal Flap Ear Canal Hair Removal

Wednesday, September 28th, 2016

 

Hair that grows on the ear is a well known phenomenon amongst men as they age. Often joked as hair that has migrated from the scalp, it appears as outcroppings of black hair from various parts of the ear. The greatest concentrations appear on the earlobes, helix and, interestingly, the tragus. Often ear hair is dark even if the man’s hair color has turned gray.

excessive-tragal-ear-hair-dr-barry-eppley-indianapolisHair on the tragus of the ear, also known as ear canal hair, is the most interesting/unusual place for ear hair to develop. It is well known to develop hair since it gets its name from the Greek word, tragos, meaning goat because its hair growth on its undersurface resembles that of a goat’s beard.

The traditional methods of ear hair removal include plucking and shaving. While effective these methods require near daily maintenance as they only remove the most visible part of the hair shaft and not the growth center. (follicle) Laser hair removal can be done for more permanent results but this requires multiple treatments, is a difficult place to treat because of the shape and location of the tragus and can be quite uncomfortable to have done.

tragal-ear-skin-flap-for-hair-removal-dr-barry-eppley-indianapolistragal-ear-hair-removal-electrocautery-dr-barry-eppley-indianapolisA surgical treatment for tragal ear hair removal can be done that is near 100% effective and can be completed in one session done under local anesthesia. This is known as tragal flap hair depilation. In this technique a skin flap is raised off of the tragal ear cartilage. The tragal skin flap is then everted and all of the dark hair follicles can be easily seen. The hair follicles are amputated by scissors and then cauterized, thus permanently removing the actual growth center of the hair.

tragal-ear-skin-flap-closure-for-hair-removal-dr-barry-eppley-indianapolisThe tragal skin flap is trimmed as it has been mobilized,  further removing any hair-bearing skin. The skin flap is then closed back over the tragus with small dissolveable sutures. No dressing is applied and the suture line remains hidden on the underside of the tragus or ear canal. Swelling and bruising are minimal to undetectable. Full healing takes place in about ten days.

Ear canal hair is difficult to permanently remove with any traditional hair treatment method. Surgical tragal flap hair removal is a highly effective one-time treatment that can be done in the office under local anesthesia with virtually no recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Vanquish ME for Non-Surgical Fat Reduction

Tuesday, August 30th, 2016

 

The market leader for nonsurgical fat reduction is Cryolipolysis or Cool Sculpting. It is the market leader not necessarily because it is the best body contouring device but because it is certainly the most heavily marketed to both physicians and patients. But it is not suitable for every patient that seeks nonsurgical fat reduction because of the limitation  of applying the paddles which deliver the cooling energy to create its effect. Thus it is usually limited to patients that have a BMI less than 25.

Vanquish Body Contouring Dr Barry Eppley IndianapolisVanquish ME is a better device for larger patients like those with BMIs over 30. Because of the large spot size and non-contact external applicators, it can treat many patients that are not suited for Cool Sculpting and other modalities. A recent study found that a series of four Vanquish treatments without manual massage resulted in an average reduction of the abdominal fat thickness of over 5mms as assessed by MRIs.

Given that 30% of the population has a BMI that is over 30, spot treatments offered by many devices would be completely ineffective. This leaves a large number of people not seeking to undergo liposuction has candidates for Vanquish treatments. Vanquish results usually become evident in just a month after beginning treatments so patients usually stay motivated to complete the treatments and often go on to a second series.

When Vanquish is combined with Exilis Ultra to increase tissue heating the amount of skin contraction and tissue tightening is enhanced. The new Cellutone also speeds he onset of results. Adding a massage component to body contouring techniques is well known to be beneficial. When added to a non-invasive fat reduction treatment series it has been shown to nearly double the amount of abdominal reduction seen.

Dr. Barry Eppley

Indianapolis, Indiana

Hydroxyapatite Granules for Facial Augmentation

Monday, July 4th, 2016

 

I get a lot of inquiries regarding the use of hydroxyapatite(HA) for facial augmentation. Some requests are for whether it will work for their facial augmentation needs. Others are with concerns about indwelling HA materials at various craniofacial implantation sites. Depending upon what you read and whom has written it, the advisability and safety of HA facial augmentation can be positive or negative.To provide some clarity to the use of HA, I have written the following brief review on the topic.

Hydroxyapatite is a calcium phosphate materials that is similar to bone (HA is 70% of the inorganic mineral in bone) and has bioactive and osteoconductive properties. Calcium phosphate materials come in a very wide variety of forms such as cements, blocks, granules and coatings and are used in many medical and dental applications. Such calcium phosphate synthetic materials come in two common forms, hydroxyapatite and tricalcium phosphate. (TCP) These two materials are often confused and are in appropriately used interchangeably. Hydroxyapatite is best thought of as non-resorbable  while TCP is resorbable. To matters somewhat more confusing there are even combined biphasic HA-TCP composites for clinical use.

It is important to realize that the term, hydroxyapatite, is really a generic one. There are many different forms of synthetic HA based on its porosity, density and how it is processed. Because it can be made fairly inexpensively there are many manufacturers around the world. Their similarities and differences are impossible to know from a surgeon and patient standpoint. Thus it would be presumptous to assume they all behave the same biologically or are even equally safe.

hydroxapatite granuleshydroxapatite granule porosityFor facial augmentation, hydroxyapatite granules are what is commonly used. Their ability to be introduced by an open syringe injection method and molded into place intraoperatively has considerable merit. Hydroxyapatite granules can be non-porous (dense) or porous. There are many different porosities of HA granules that are usually measured in microns such as ultrasmall porosity (10-50 µm where even capillaries have a hard time getting in), small porosity (50-150 µm which is amenable to both blood vessel and bone ingrowth) and medium to large porosities. (100-300 µm and 500-1000 µm) It is not known which porosity is more advantageous, if any, for onlay facial augmentation use. It is generally believed that porous HA granules in the range of 50 to 150 µm are ideal from a biologic perspective although no comparative clinical studies have ever been done.

There is extensive clinical evidence that hydroxyapatite granules are very safe, well tolerated and exhibit substantial bony ingrowth/overgrowth. I have seen and treated many HA granule facial augmentation patients and have seen their results both preoperatively by 3D CT scan and intraoperatively for removal/adjustment. I have always been impressed by the bony growth in and around the granules. Inflammatory reactions and bone destruction/degradation have never been observed.

Hydroxyapatite Jawline-Augmentation-Dr-Barry-Eppley-IndianapolisBut what I have also been impressed with is their general lack of smoothness and very lumpy appearance. They create a bone surface that is anything but a smooth and regular contour. Whether this is due to the irregularity of the bone ingrowth into the granules or that the laying down of the granules occurs in a lumpy fashion is speculative. I would say it is both but the biggest culprit is probably that it is virtually impossible to have it placed in a smooth and lump-free fashion. There is no linear flow to a HA granule injection placement. Thus it is assured that it can not be deposited on the bone’s surface as smoothly as that of a hyaluronic-based injectable filler for soft tissue augmentation for example.

In conclusion I like hydroxyapatite granules for onlay facial augmentation for its safety, effectiveness and method of application. But its aesthetic effects are often problematic and severely limits its use. For small craniofacial augmentation sites it has a role but patient selection is critical. It works best when it is not asked to do too much.

Dr. Barry Eppley

Indianapolis, Indiana

First U.S. Penis Transplant

Monday, May 23rd, 2016

The first U.S. penis transplant was performed in Boston on May 8 and 9th by a team lead by a plastic surgeon. This is the third such penis transplant in the world. The 64 year-old male patient had his penis previously removed due to cancer. The operation took 15 hours over two days with the penile transplant coming from a deceased donor. The transplant surgery was part of a research program whose ultimate goal is to aid combat veterans with significant pelvic injuries as well as those men who have had penile resection due to cancer and penile amputations due to trauma.

Like all organ transplant surgeries, they are a marvel and plastic surgery has been at the leading edge of many of them for decades. While face transplants have gotten the most attention over the past few years, it is a far more complex type of tissue transplantation than that of a solid organ like the penis.

penile anatomyBut a penis transplant is still a challenge and this single operation belies the work that lead up to it. The hospital team spent several years preparing for the penile transplant which involved a lot of cadaver work to learn the intricate details of the anatomy as well as becoming proficient at harvesting a penis from a donor. Like so many things in life, a  single event if it is to be successful comes with a lot of preparation. Every new type of tissue transplant has required thousands of hours of preparation for the actual event. While microsurgery and reattaching blood vessels and nerves has been around for over 25 years, performing it on a new organ still requites a lot of forethought.

Plastic surgery continues to develop new techniques for reconstructive and aesthetic surgery. What will be learned for performing a pioneering surgery like penis transplants will one day translate into other more everyday surgical techniques. That has been the history of plastic surgery over the past 100 years.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Congenital Lip Nevus Surgery

Saturday, April 30th, 2016

 

Background: The congenital melanocytic nevus is one form of a mole that is present at birth. It occurs in about 1% of all births and occurs about 15% of the time on the face. It usually appears as a very distinct brown-colored lesion whose color is very homogenous. One of its distinct features is that it is associated with hair that is usually dark in color.

The melanocytic nevus grows proportionally as the child grows and will usually become thicker and raised above the surrounding skin’s surface. Its hair growth becomes greater after puberty and the hair growth may become darker in color. Very large congenital nevi are at higher risk for malignant conversion into melanoma. And for this reason early excision is standard practice to eliminate this potential risk.

Melanocytic nevi are classified by size based on diameter. Small size are those that are less than 2 cms. But when they occur on the lip a 1 or 2 cm nevi can be considered large when considering how to reconstruct it after excision.

Case Study: This 13 year-old female  was born with congenital nevus on her lip. It grew proportionately with her and developed a lot of hair growth. It was a source of ridicule for her in school and requires regular hair trimming. She was finally ready to have it removed. Because of its size, treatment options included serial excision, total excision with skin grafting and excision with local flap reconstruction.

Upper Lip Nevus Excision and Skin Grafting result front view Dr Barry Eppley IndianapolisUpper Lip Nevus Skin Graft Neck Donor Site Scar Dr Barry Eppley IndianapolisUnder general anesthesia, the entire lip nevus was excised with 1mm margins. A full thickness skin graft was harvested from a skin crease in the lower neck. It was applied to the excision site and covered with a tie over bolster. The bolster was removed 10 days later. When seen none months after the procedure, the skin graft had matured and the lip was soft and supple without distortion. The harvest site from the neck had a barely discernible scar.

Upper Lip Nevis Excision with Skin Grafting result oblioque view Dr Barry Eppley IndianapolisThe benefits of full thickness skin grafting are that there are no additional scars created in its reconstruction. It is essentially trading off one patch of discoloration for another. But that tradeoff is easy since a lighter color match of skin without hair that is flat is a certain improvement. Consideration can be given later to scar treatment methods such as laser resurfacing and even serial excision.

Highlights:

1) Congenital lip nevi are present at birth and are usually associated with extensive hair growth as the child develops.

2) Large lip nevi can not be primarily closed after total excision without significant lip distortion.

3) Complete excision of congenital lip nevi requite full thickness skin grafting to prevent transverse lip deformities/constriction.

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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