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Dr. Barry Eppley

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Archive for the ‘product reviews’ Category

Product Review – Mentor Xtra Breast Implants

Sunday, November 5th, 2017


Silicone breast implants have been back in clinical use for the past decade. While there are various features of these implants, such as the gel composition and the characteristics of the enveloping shell, that get a lot of attention one overlooked feature is that of implant fill. This refers to how much the enveloping shell is filled which impacts the implant’s shape.

Historically silicone breast implants have been not fully filled. This creates the well known ‘ashtray’ effect where a crater or concavity exists on the top of the implant when it is laying on a flat surface. (or when the patient is in the horizontal supine position) It was never clear to me why the implants were never fully filled but my assumption is that a lower fill made them more deformable (to fit through a smaller incision) and made them feel softer. But by so doing more folds occur in the implant shell in the vertical sitting or standing position and less fullness is retained in the upper half of the implant.

Breast implant manufacturers have begun introducing more fully filled silicone breast implants that go by different names. This is illustrated in the new Mentor Xtra silicone breast implants which received FDA approval in April 2017 and have now become available for clinical use. They are available in a wide range of sizes and with different projections as well.

When laid side by side to ‘normal fill’ implants, the Mentor Xtra implant shows how the implant’s projection and shape is better maintained. (no ashtray effect) There is also less shell wrinkles when the implant is positioned on its side, which is how it would be in a patient when they are standing or sitting. Less wrinkling or implant folds also decreases the risk of developing fold flaws (tears in the implant shell), also known as implant ruptures.

It is finally time that more fully filled silicone breast implants became available. This has been a ‘flaw’ in breast implant designs/offering for a long time. The merits of having underfilled implants that have an ashtray effect has always been unclear to me.

Dr. Barry Eppley

Indianapolis, Indiana

Product Reviews – Allofill Injectable Filler

Friday, October 27th, 2017


Injectable fillers have evolved considerably since their introduction was back in 1981. While originally an xenogeneic collagen-based product, it has become largely populated by hyaluronic acid-based products. Given their synthetic origins, almost of current injectable fillers are temporary and have variable durations of volumetric effects. Despite new injectable fillers becoming available every year, they are merely variations of current product formulations.

Allofill represents a new injectable filler that is different on both composition and biologic effects. This is a ready-to-use allograft-derived filler that retains the natural extracellular matrix (ECM) of allogeneic-derived fat tissue. Human fat is decellularized to obtain a tissue scaffold that has biologically active components. This allows the body to grow into this matrix and populate it with the body’s own cells. In essence this is a form of injectable tissue engineering.

Allofill is made from cadaveric fat tissue and is used to fill soft-tissue defects as an alternative to surgical injectable grafting which uses your own tissue. Conventional injectable fat grafting requires a surgical liposuction procedure to obtain and process one’s own fat for injection. In a traditional fat grafting procedure fat is harvested from one part of he body and is injected into another part of yourface. With Allofill harvesting your own fat isn’t necessary since Allofill is ready to use off the shelf and can be applied like any other off-the-shelf injectable filler.

Allofill currently comes in 3cc syringes and is refrigerated until it is used. It has a two year shelf life.

Dr. Barry Eppley

Indianapolis, Indiana

Product Reviews – Botox for Forehead Wrinkle Lines

Sunday, October 8th, 2017


Botox is the most popular form of injectable aesthetic therapt. It has an established history of success in managing problematic facial movements that cause undesirable facial expressions and ultimately skin wrinkles. It was formally FDA-approved well over a decade ago for the treatment of glabellar (between the eyebrow) wrinkles lines and has gone on to receive a similar FDA-approval for crow’s feet wrinkles as well.

Even though formal approval for other types of adverse facial wrinkles and expressions did not exist, Botox has been long been done ‘off label’ by just about every injector that has ever used it. Other aesthetic facial issues such as in horizontal lines across the upper nose (bunny lines), in the neck for platysmas bands as well for the downturned mouth corners, to name a few, are widely done.

Recently Botox was FDA-approved for the treatment of horizontal wrinkle lines. Long a companion injection site with that of glabellar wrinkle lines, it now official that it can be used in this facial area as well. It has been common to treat vertical glabellar and horizontal forehead lines as a combined injection treatment. I would say that it is more common to treat both areas together that it was to treat the glabellar area alone.

What does FDA-approval of this Botox use really mean? It really just substantiates what every injector has observed…that is both safe and effective for use in the forehead. Clinical trials reported by Allergan demonstrated that Botox injection was more effective than a placebo in reducing the severity of forehead lines.

Botox injections creates this forehead effect by temporarily weakening the frontalis muscle which runs vertically across the forehead. Less frontalis muscle movement softens existing deep wrinkles lines and prevents new ones from forming. Its duration of effect is the same as anywhere else on the face with an effect of three to four montyhs.

Dr. Barry Eppley

Indianapolis, Indiana

Cellutone – New Technology for Cellulite Reduction

Wednesday, August 16th, 2017


Today’s non-surgical body contouring can be done by wide variety of devices that produce their effects through different energies. From mechanical to ultrasonic to radio frequency, externally applied energy-based treatments have proven effects on fat reduction and skin tightening. Unlike surgery, these body contouring treatments take time to work and patients will go through a series of treatments spread out over weeks to months for their full effects to be seen.

One of the newer energy-based body contouring treatments is that of Cellutone. This is a device that uses therapeutic mechanical vibrations. This oscillating massage therapy improves the circulation, enhances lymphatic drainage and remodels collagen fibers, all effects that help improve the lumps and bumps associated with cellulite and improves skin texture. It can be used in a variety of body areas including the stomach, buttocks, thighs and flanks to name the most common treatment areas that are associated with the occurrence of cellulite.

What makes Cellutone unique from other cellulite treatments is that it uses targeted mechanical vibrations which  are stronger and go deeper into the tissue. This translate into fewer treatment sessions and earlier visible results.

The application of Cellutone through a special handpiece is pain-free and has no downtime. There is no need to take off work and stop any form of physical activity after a treatment. It is applied by gentle pressure and is done in a square-shaped grid motion across the skin of the treated area. The vibrations cause no pain but mild and very temporary side effects after is common and can include redness, itching and some very minor swelling. The most common treatment plan is a series of 4 to 6 sessions over a few weeks.

Cellutone can done alone or used with other body contouring treatments for an enhanced effect of their treatments. When combined with Vanquish or Exilis better fat reduction and skin tightening can be seen. It is also a useful postoperative treatment after liposuction to improve the resolution of swelling and shaping of the skin back down after the fat reduced treatment areas.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Juvederm Vollure XC

Friday, March 24th, 2017


With now over 25 synthetic injectable fillers available in the U.S., one would think there is little need for further filler products. But the ability to modify hyaluronic acid filler structures to create different aesthetic effects assures that more such filler products will continue to become available.

Juvederm Vollure XC Dr Barry Eppley IndianapolisJuvederm Vollure XC has just become FDA-approved for injection into moderate to deep facial wrinkles such as the nasolabial folds. It is formulated with proprietary Vycross technology, which blends different molecular weights of hyaluronic acid, contributing to the filler’s long duration. Juvederm Vollure XC will be available in the United States in April 2017. This specific filler is not new in other parts of the world as it was first approved in Europe under the name of Juvederm Volift in 2013.

In the clinical trial that led to its approval, 59% of patients saw improvement in moderate to severe nasolabial folds for up to 18 months, with 82% of patients saying they were very satisfied at 6 months and 68% at 18 months. With a duration that has been shown to last up to 18 months from the initial or touch-up injection in a majority of patients, this is the longest lasting result shown in a clinical study in the nasolabial folds to date.

Like all injectable fillers it has typical side effects such as swelling, tenderness, bruising, firmness lumps/bumps, redness, pain, discoloration, and itching. Other than lumps of the material these side effects resolved within one week after injection.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Restylane ReFyne and Restylane DeFyne

Sunday, March 5th, 2017


With over 25 synthetic injectable fillers on the US market it can be argued that how may more do we really need. But each new injectable filler offers some advantage and thus there is room for more. These growing number of injectable fillers has led to the concept of a toolkit of injectable treatments that allows customized use for specific facial aging indications  and applications.

Restylane Refyne and Restylane Defyne Dr Barry Eppley IndianapolisThe most recently approved filler is Restylane Refyne and Restylane DeFyne.  These have been FDA approved for the treatment of nasolabial folds. The main difference with these Restylane products and other hyaluronic acid fillers in in their inherent flexibility due to the proprietary XpresHAn technology. (X = cross-linking, Pres = pressing gels through mesh for calibration, HA = hyaluronic acid) This allows facial expressions (smiling, frowning, etc) to not feel stiff and more natural due to the flexibility of the filler material.  While new to the U.S. the product has been used in Europe for years under the name of  Emervel.

Restylane Refyne is the most flexible and provides support for moderate lines while Restylane Defyne is less flexible and is intended to support deeper lines. Their advantage amongs injectable fillers is their ‘Natural Expression in Motion’. Most patients treated felt that their facial expressions were unaffected and the location of the filler was not detectable.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Natrelle Breast Implants (Inspira Round Gel)

Sunday, December 25th, 2016


Silicone breast implants continue to evolve both in its external shell and the gel that resides inside it. The silicone gel has become far less like the liquid it originally was many years ago. The silicone has become more firm or cohesive through increased crosslinking of the silicon molecules. The urban term for these newer type of breast devices is known as ‘gummy bear breast implants’. But the manufacturers of them use the term ‘highly cohesive’ or more form stable.

natrelle-inspira-round-breast-implants-indianapolis-dr-barry-eppleyAllergan has offered silicone breast implants for years, known as the Natrelle breast implants line. They have had a highly cohesive gel in their shaped implants since 2013. (Natrelle 410 Anatomically Shaped Breast Implants) They have recently introduced this more highly cohesive gel in a round implant form. (Natrelle Inspira Round Gel Implant) The purpose in so doing is to achieve two effects: 1) hold the implant’s shape better, particularly in an upright position, to maintain upper pole fullness, and 2) for the gel to stay in place when the implant is either ruptured in vivo or cut in half when outside of the patient.

natrelle-inspira-round-gel-breast-implants-dr-barry-eppley-indianapolisAllergan’s tested comparative physical features show it is 51% more cohesive that Mentor Memory Gel and 37% more cohesive than Sientra’s style 106 implant. Comparing form stability (what happens when the implant sits straight up), the Allergan  implant was 47% more form stable than Mentor Memory Gel and 28% more form stable than Sientrs style 106 implant.

It is clear that increased gel cohesiveness is a desirous feature of a silicone breast implant. This is true both for how the implant performs long-term in the patient but also in how it is perceived by potential patients. (patients want ‘gummy bear’ breast implants) Each manufacturer now has their own version of them and they actively compare their gel cohesiveness and form stability. Natrelle breast implants now has a very competitive round silicone gel implant that is truly a gummy bear type.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Costal Cartilage Allografts in Rhinoplasty

Monday, August 8th, 2016


Augmentative rhinoplasty requires either a graft or implant to perform. In most cases the use of the patient’s own septum or ear donor site is adequate. In more substantative dorso-columellar augmentations consideration must be given to either rib grafts or synthetic implants to achieve the desired effect. In some cases even an amalgamated approach can be used combining an implant (dorsal) with a cartilage graft. (tip)

Rib Grafts in Rhinoplasty Dr Barry Eppley IndianapolisThere are well known advantages and disadvantages to both rib grafts and implants. Neither one is perfect. Rib grafts require a donor site and can be prone to warping. (if not diced) Implants have a higher risk of infection and can become displaced over time.

A third alternative does exist, however, that marries the benefits of both rib grafts and implants….that of cadaveric costal cartilage grafts. Harvested from cadavers through the Musculoskeletal Transplant Foundation (MTF), this allograft costal cartilage has several advantages. It eliminates the need for a donor harvest site which decreases operative time and lessens patient’s postoperative pain and scarring. They are minimally processed which helps preserve their biologic and mechanical integrity. (unlike irradiated or freeze-dried rib grafts from the past)

What is really surgically convenient and for the patient’s benefit is how the form in which the grafts are prepared. They come in either segments or sheets in a variety of lengths, widths and thicknesses. The costal cartilage sheets are greater than 3cms in length, 1 to 2 cms in width and around 2mms in thickness.  The costal cartilage segments are greater than 3 cms, have widths up to 3 cms and thicknesses up to 20mms. It has a comparative cost to that of many nasal implants.

The costal cartilage allograft is another augmentative rhinoplasty option between rib grafts and synthetic nasal implants.

Dr. Barry Eppley

Indianapolis, Indiana

The Omnimax MMF System – Product Review

Sunday, March 13th, 2016


Jaw surgery has a long association with the need for maxillomandibular fixation. (MMF) Wiring the jaws together is an essential first step in many types of maxillofacial surgery. Whether it is in elective orthognathic procedures, the treatment of jaw fractures or in the reconstruction of the jaw after cancer reconstruction, the application of maxillomandibular fixation is essential. Putting the teeth together in the correct occlusion (bite) ensures that the jaw realignment/restoration surgery results in a satisfactory functional outcome.

The historic and standard approach to the application of maxillomandibular fixation is the application of arch bars to the teeth with multiple interdental wires. (usually 26 gauge) This ‘gold standard’ MMF technique has been used with various modifications for over 100 years with no real changes in the concept or technique. While unquestionably effective, it is tedious and time-consuming to apply and always involves some glove integrity violation and even skin penetration. It is by far the most despised maxillofacial techniques by all surgeons of any specialty. I have applied MMF on over 1,000 cases in my career and can do in an average 15 to 20 minutes. Those plastic surgeons with far less experience (e.g., residents and young surgeons) can easily take 45 minutes to an hour of operative time to get the bars and wires correctly applied.

In addition arch bars and interdental wires pose hygiene challenges for the patient after surgery and their high compressive forces on the teeth and gums results in significant occurrences of periodontal (gum) recession via papillary blood flow compromise.

Omnimax Maxillomandibular Fixation System Dr Barry Eppley Indianapolis Omnimax MMF System Indianapolis Dr Barry EppleyThe Omnimax MMF system (Zimmer Biomet) represents breakthrough technology and is a real game changer for getting the jaws and occlusion properly aligned. While other hybrid MMF systems have emerged in the past five years, I find that they have more limited uses with their own set of problems. (e.g., mucosal tissue overgrowth of the plates and screws and a high number of screws used per arch to name the top two)

Omnimax extended screw design Dr Barry Eppley IndianapolisThe Omnimax system overcomes these MMF issues by several design innovations. The plates have a better segmentalized design with extended screw slots and are composed of an anodized titanum, all factors which contribute to less soft tissue irritation. But the key breakthrough design feature is the EXTENDED SCREW INSERTION SLOTS. This permits the MMF plate to stand off of the soft tissues while still being stabilized to the bone. This is a brilliant innovation in screw design that is proprietary to the Omnimax MMF system. Not only does the plate no longer compress the soft tissues but the stand off feature allows intermaxillary wires to be applied without creating compressing and necrosing gingival tissues.

Omnimax MMF system in place Dr Barry Eppley IndianapolisThe Omnimax MMF system with the innovative plate standoff feature due to the screw design finally overcomes the traditional problems with hybrid plate and screw MMF approaches. It decreases the number of screws needed for application (from 14 in other systems to 8) and improves intraoral hygiene and tissue health for the patient after surgery. But of equal importance in terms of operating room efficiency it changes the application of MMF from an average 45 minutes to 15 minutes (or less) with a far less risk of glove puncture.

Omnimax MMF System kit Dr Barry Eppley IndianapolisIn my opinion the new gold standard for maxillomandibular fixation has finally arrived. The simplicity and innovative design of the Omnimax MMF system will change the perception of this basic maxillofacial technique from one of contempt to possibly even pleasure.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Vitagel in Plastic Surgery

Friday, February 26th, 2016


The most common expected early outcomes and complications from many types of plastic surgery are various types of undesired fluid collections. These are caused by bleeding (bruising and hematomas) as well as prolonged lymphatic leaks. (seromas)

While the body has many natural clotting and healing mechanism to limit the occurrence or extent of these fluid collections, they can be frequently overwhelmed or not optimally effective. Plastic surgeons are well aware of this potential and employ a variety of  strategies to help including intraoperative electrocautery and hemostatic materials as well as the use of postoperative drains and pressure dressings.

Vitagel Indianapolis Dr Barry EppleyThe past decade has seen the advent of adjunctive biologic approaches that can be applied during surgery to work with the body’s natural hemostatic and healing mechanisms. One such agent is VITAGEL.This is an FDA-approved, composite liquid hemostat that combines the thrombin and collagen with the patient’s own plasma. When applied to human tissues, Vitagel creates an adherent gel and an impermeable barrier to blood flow. This helps control bleeding and facilitates healing using the patient’s own biology.

Vitagel Dr Barry Eppley IndianapolisVitagel is promoted as a surgical hemostatic product that combines microfibrillar collagen with thrombin, fibrinogen, and platelets. This unique combination of components forms a 3-D scaffold of collagen and fibrin which is augmented with activated platelets.This is created during surgery by using a draw of the patient’s blood which is spun down by a centrifuge to create an extract of plasma and platelets. This is then mixed with prepackaged thrombin and collagen to create the final hemostatic product. By using the patients own blood, the risk of viral transmission associated with products containing pooled human donor components is eliminated.

Microbrillar collagen in Vitagel Dr Barry Eppley IndianapolisOne very unique component of Vitagel is the microfibrillar collagen.  Collagen is a well known essential element for both inducing the coagulation cascade as well as promoting healing. The microfibrillar structure allows for better coherence of the collagen fibers to irregularly shaped bleeding sites.This type of collagen also aids the healing process through the formation of a biologically active 3-D scaffold for cellular ingrowth and fibroblast attachment.  Such a scaffold becomes a template for new tissue growth. This is unlike any other surgical hemostatic agent.

Vitagel Spray Indianapolis Dr Barry EppleyVitagel can also be applied to the surgical site in a variety of ways including a standard spray and a powered aerosolized mist. This ensures optimal coating of the tissues even into the smallest crevices.

Vitagel has great application for many plastic surgery procedures that involve the creation of large skin and tissue flaps. Such procedures as tummy tuck and facelifts, for example, involved the undermining of large tissue flaps for which drains are commonly used and the risk of hematomas and seromas are well known. The use of Vitagel would help decrease these risks and may either eliminate the use of drains or reduce the length of time they are in after surgery. At the least the amount and duration of postoperative bruising and swelling may be lessened.

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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