EXPLORE
Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘technical strategies’ Category

Technical Strategies – Parietal Eminence Skull Reduction

Thursday, September 8th, 2016

The reduction of skull lumps and bump is a not uncommon request in skull reshaping surgery. Raised areas of the skull can occur for a variety of reasons although the most common is congenital, being just the way that the skull formed.

One unique type of skull lump is not really a lump at all. Known as the parietal eminence it develops from the parietal bone. This skull bone is situated on the sides and roof of the skull, is quadrilateral in shape and has four borders and four angles. Its external shape is convex and near its center is the parietal eminence from which it is formed by ossification. This ossification process begins about the eighth week in utero and gradually extends outward in a radial pattern from the eminence to the margins of the bone.

Because the parietal eminence is the epicenter of the parietal bone it can appear as a prominent bump. Roughly the size of a quarter it can discerned in oblique profile views and, even with hair, can be easily palpated.

parietal-eminence-reduction-by-burring-dr-barry-eppley-indianapolisParietal eminence skull reduction is a form of ‘spot’ cranioplasty. Using a handpiece and drill the prominent high spot of the bone can be satisfactorily reduced. In doing so there are two key components of the procedure. The first important technique is how the bone is reduced. A small skull problem deserves a small incision. Using a high speed handpiece and burr around hair through a small incision runs the real risk of getting hair entangled and pulled out  by the rotation of the burr. Guarding the full length of the burr with a rubber guard allows a smooth reduction to be safely done without risk of hair injury.

parietal-eminence-reduction-incision-dr-barry-eppley-indianapolisWhen making an incision for parietal eminence skull reduction, the incision need to be vertical in orientation and only about 4.5 cms long. But rather than just a straight line, it is aesthetically better to create an irregular zigzag line with a few sharp angles placed between the visible hair shafts. This allows the incision to heal amongst the hair in the most inconspicuous manner.

Parietal eminence skull reduction is a very effective procedure that can be done with limited scalp and hair trauma that leaves an inconspicuous scar.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Versatile Temporal Implant

Sunday, May 8th, 2016

 

Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.

Temporal Implant Design Dr Barry Eppley IndianapolisThe first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.

Temporal Implants modifed use Dr Barry Eppley IndianapolisBut some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.

The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Diced Rib Graft Injection in Rhinoplasty

Tuesday, April 12th, 2016

 

Primary or secondary correction of nasal bridge deformities is now well known to be corrected by injectable fillers. The use of hyaluronic acid-based (HA) injectable fillers provides a quick and very directed approach to a wide variety of nasal contour deformities. While effective, no HA filler to the nose provides a permanent contour correction in the vast majority of patients.

I have run across a handful of patients that stated they had gotten one HA injection to the nose years ago and the result was sustained. But it is hard to know whether this is merely cosmetic accommodation or was indeed a ‘permanent’ result. I suspect that of the nasal contour issue was significant, such a permanent result would not have been seen. I know from injecting a lot of dorsal hump patients with HA fillers to camouflage it (placing filler above the hump to create a straight dorsal line) that such filler volumes are not sustained in the nose.

Diced Rib Graft Injection Preparation Dr Barry Eppley IndianapolisAn alternative and permanent options for larger primary or secondary dorsal line defects is that of a diced cartilage graft injection. This is a concept that, while injected, must be differentiated from that of HA filler injections. This is where cartilage grafts from either the septum, ear or rib are processed to make them injectable. This is done by cutting (dicing) them into small 1 x 1mm cubes (or smaller) and placing them into an open barrel 1ml syringe.

Diced Rib Graft Injection Preparation 2 Dr Barry Eppley IndianapolisThrough an intranasal (intercartilaginous) incision, a tunnel is made on the dorsum up onto the upper dorsal defect area. (frontonasal junction, radix, nasal sidewall) The syringe is introduced and the compressed cartilage grafts are injected in the desired amount and shaped externally. The grafted area is taped to hold the desired shape for 7 to 10 days.

While many diced cartilage are traditionally wrapped in surgical or fascia, there is a role in smaller nasal dorsal defects for direct injection of the cartilage. The small nasal tunnel and confinement of the syringe allow the cartilage particles to be precisely delivered.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Large Skull Reduction

Saturday, April 2nd, 2016

 

skull layersWhile there are many different types of skull reshaping surgeries, the most limiting is the desire to have an overall smaller head. Because of the skull’s thickness, there are limits as to how much of the skull thickness that can be reduced. While there are great variabilities in the thickness of the human skull, safe reduction is limited to removal of the outer cortical layer. The skull is exactly like an Oreo cookie with three layers, two outer hard layers (cortex) and an inner softer marrow layer. (diploic space) For reasons of brain protection and bleeding, aesthetic reduction should go no further than the outer layer of the ‘cookie’.

The typical outer coretx of the skull is anywhere, on average, from 4 to 7mms thick in humans. This thickness is affected by gender, age and ethnicity. While reduction of such a  ‘limited’ amount of skull thickness may not seem like much, it can appear much bigger than one would think when a broad surface area of it is removed. This is particularly true across the top of the skull between the temporal lines and in the forehead and back of the skull. Reduction along the sides of the skull is more greatly impacted by muscle reduction than it is by bone removal.

When doing large skull reduction areas, a burring technique is used as the most efficient and safest bone removal method. Burring allows for a controlled bone removal method so one can judge how when one is getting close to the diploic space of the skull. But when burring large skull areas it can be difficult to get it perfectly smooth and even across its convex surface. The procedure is also tedious and time consuming.

Skull Reduction technique 1 Dr Barry Eppley IndianapolisSkull Reduction surgical technique 2 Dr Barry Eppley IndianapolisThe technique that I have developed for large skull reductions is a ‘checkerboard’ method. A horizontal cut with a burr is first made to establish the depth of the reduction from one temporal line to another. Then additional horizontal lines are made over the desired skull reduction area. Then vertical burr cuts are also made to create a grid or checkerboard appearance.

Skull Reduction surgical technique Dr Barry Eppley IndianapolisSkull Reduction surgical technique 4 Dr Barry Eppley IndianapolisThis checkerboard skull pattern then allows one to reduce each individual square sequentially. This helps ensure that the overall bone reduction is done as even as possible and allows one to do it faster and very safely. Always knowing where the diploic space is located gives the surgeon better control of the bone being removed.

Any large skull reduction done for aesthetic purposes is accomplished by removing the outer cortex through bone burring. This checkerboard technique allows for both precision and safety.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Screw Fixation of the Premaxillary-Paranasal Implant

Monday, March 28th, 2016

 

paranasal implant anatomy pyriform aperture dr barry eppley indianapolisAugmentation of the central midface can be done by placing an implant along the base and sides of the nose. Known as the pyriform aperture, it is the bony outline of the nasal cavity which makes a hole in the facial skeleton to the back of the throat. The soft tissue and cartilage structure of the nose sits on top or in front of it.

Peri-Pyriform Implant Dr Barry Eppley IndianapolsParanasal Implant placement Dr Barry Eppley IndianapolisThe pyriform aperture area can be augmented by a standard preformed implant known as the peri-pyriform implant. It has bilateral wings that augment the paranasal or sides of the pyriform aperture and a connecting center piece which crosses the premaxillary region along the bottom of the nose. Technically this implant should be called a premaxillary-paranasal implant. It is a versatile implant since it can be sectioned to just do paranasal augmentation or its wings can be removed to create just a premaxillary implant.

Paranasal Implant Placement Dr Barry Eppley IndianapolisThe premaxllary-paranasal implant is placed through a low anterior vestibular incision up under the upper lip. It is important to place the incision above the fixed mucoperiosteal to leave a cuff of tissue to create a good closure. Sunperiosteal dissection is done up to the anterior nasal spine and around the sides of the pyriform aperture. It is important to stay close to the edge of the bone but to not violate the nasal mucosal lining. The implant is placed snug up against the anterior nasal spine and along the sides of the pyriform aperture. Two 1.5mm screws are placed through the wings of the implant to secure it to the bone.

The premaxillary-paranasal implant is the only implant that can provide central face augmentation. It has a LeFort 1-like effect on the base and sides of the nose. Firm fixation to the bone by microcrews is a simple and effective method to ensure its postoperative placement and long-term stability

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Head Widening Implants

Monday, February 15th, 2016

 

The width of the side of the head  is controlled by the shape of the temporal bone and the thickness of the temporalis muscle, all located above the ear. While many think the bone is the main contributing factor, the thickness of the temporalis muscle should not be underestimated. By CT scan measurements it can be seen that the temporalis muscle usually makes a bigger contribution than that of the bone to the width of the side of the heasd.

Regardless of the anatomic makeup of the width of the head, widening the narrow head must be done by either onlay augmentation of the bone (submuscular) or onlay augmentation of the muscle. (subfascial) Which implant location is best depends on whether the augmentation involve just the posterior temporal region (above the ears) or also the anterior temporal region as well. (by the side of the eye)

Head Widening Implants (anterior and posterior temporal implants Dr Barry Eppley IndianapolisHead Widening Implants (incision and subfascial dissection) Dr Barry Eppley IndianapolisMost head widening implants augmentation include both the anterior and posterior temporal regions. This can be accessed through a single 4cm incision placed in an intermediate location in the temporal hairline. Using a subfascial incision and pocket dissection, extended anterior and larger posterior temporal implants can be placed through the same point of temporal incisional access.

Head Widening Implants (implant placement and subafscial closure) Dr Barry Eppley IndianapolisHead Widening Implants (incision closure) Dr Barry Eppley IndianapolisAfter the placement of both anterior and posterior temporal implants in the subfascial pockets, the fascia os closed over the them. The skin closure is done in a two layer fashion with resorbable sutures.

Head widening or complete temporal augmentation can be done through a single small temporal incision. Two implants are needed to increase the volume of both the anterior and posterior temporal regions.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Extended Temporal Implants

Sunday, February 14th, 2016

 

Temporal implants have become the surgical approach to the treatment of temporal hollowing.  They offer a rapidly performed permanent solution that eclipses the temporary and inconsistent effects of synthetic fillers and fat injections. These implants are placed in the subfascial location on top of the temporalis muscle through a small vertical or obliquely oriented incision back in the temporal hairline.

As the use of temporal implants has increased, new styles have emerged. The initial temporal implant design was designed to treat the deepest part of the temporal hollows by the side of the eye. These implants only went up about as high as the lateral brow bone.

Extended Anterior Temporal Implant Dr Barry Eppley IndianapolisBut as more experience with temporal implants has evolved, it become clear that the extent of bothersome temporal hollowing can extend all the way up to the side of the forehead. (anterior temporal line) This has led to an extended style of temporal implants that provides some augmentation much higher than the standard style. (up to 6.5 cm vertical height from the zygomatic arch)

Temporal Implants Incision and Insertion Dr Barry Eppley IndianapolisWith such a larger temporal implant, the concern would be that a much larger incision would be needed for its placement. To avoid more than a 3 cm to 3.5 cm incision, the key is to make the subfascial pocket through a small incision. This is easy to do with instruments in a blind fashion. Then the implant can be inserted lengthwise in a rolled fashion. Once making its way through the small incision, the implant is unfurled and rotated into the proper position.

Larger styles of temporal implants can still be inserted through relatively small temporal hairline incisions. This makes the appeal of temporal implants for larger areas of temporal hollowing equally appealing as smaller amounts of temporal hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Biceps Implants

Wednesday, February 10th, 2016

 

tricep muscleAugmentation of the upper arm is a combination of development of the biceps and triceps muscles. The biceps is the most recognized of the two upper arm muscles and the most pursued in terms of exercise development and arm flexing. The biceps muscle is a two-headed muscle that extends on the anterior surface of the upper arm from the shoulder down to the elbow. The muscle originates on the scapular bone and inserts across the elbow on the upper forearm bones. Its main function is to flex and rotate the forearm

While weight training and other forms of exercise are the best way to develop a larger and more prominent biceps muscle, there are biceps implant surgeries to bypass the natural augmentation methods. Biceps implants can be placed in the subfascial location over the muscle to enhance its muscular profile.

Biceps Implants Markings and Incision Dr Barry Eppley IndianapolisThe location of biceps implants is placed over the length of the muscle. But it is very important when making the implant location markings that it takes into account the shortening or contraction of the muscle. The distal length of the muscle should be marked when the muscle is maximally contracted when the elbow is bent at 90 degrees and the forearm is supinated.

Biceps Implants Incision and Pocket Dissection Dr Barry Eppley IndianapolisBiceps implants surgery is done in the supine position through an incision placed high in the armpit. This is the identical incision used for the placement of pectoral implants. Iyt does not need to be more than 3.5 to 4cms in length. This iincision is up under the lateral edge of the pectoralis muscle so it will be fairly hidden when it heals.

Biceps Implants Incision and Closure Dr Barry Eppley IndianapolisThe biceps muscle fascia can be identified under the fat underneath the incision down towards the arm. The fascia is incised and the subfascial pocket is dissected with a long smooth instrument down to just above elbow. A silicone contoured carving block (Implantech) is used and carved to length as needed. The implant is easily inserted along the full length of the subfascial pocket.

The fascia is closed and the overlying skin closed in two layers. An ace wrap along the full length of the arm is used as the only dressing.

Biceps implant surgery produces an instant muscle enhancement effect.The subfascial pocket approached from an axillary incision avoids any major neurovascular structures and enters the fascia where the two heads of the biceps muscle become unified.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Triceps Implants

Saturday, February 6th, 2016

 

Silicone implants are available for male muscle augmentation at a variety of body sites. The most well known male body implants are the pectoral and calf implants. Implants for the arms and shoulders can also be done but they are far less well known and performed. Arm implants can be done for the bicep and tricep muscles and are most commonly done together.

tricep muscleThe triceps muscle, technically known as the triceps brachii muscle (three headed muscle of the arm), is the single large muscle on the back of the arm. Its contraction is what causes the straightening of the arm by extension of the elbow joint. Aesthetically the triceps muscle is not thought of as important as the anterior biceps muscle. But augmentation of the biceps muscle can not really be done without triceps enlargement to keep a well balanced muscular upper arm.

Triceps Implants Incision Dr Barry Eppley IndianapolisThe placement of triceps implants is best done under general anesthesia in the prone position. With the arms extended out on arm boards and the elbows bent at 90 to 120 degrees, good access is obtained to the back of the arm. With this positioning, a 3.5 cm skin incision can be made in the posterior axillary skin crease.

Triceps Implants Insertion Dr Barry Eppley IndianapolisTriceps Implants Insertion 2 Dr Barry Eppley IndianapolisDissection is carried down to the triceps  fascia through a moderate layer of subcutaneous fat. There are no major nerves or blood vessels that are in the path of this dissection. The fascia is incised and a subfascial plane is easily dissected down the whole back of the arm  to within a few centimeters of the elbow. A soft flexible silicone triceps implant (contoured carving block, Implantech) is sized, cut to length, and then thread into the subfascial pocket. It is important that the implant is positioned exactly on the back of the arm and stays passively below the fascial incision.

Triceps Implants Incision Closure Dr Barry Eppley IndianapolisAfter the implant is adequately positioned, the triceps fascia is closed as well as the dermis of the overlying skin. The skin is then closed with a subcuticular suture.

The surgical technique for triceps implant placement is highly aided by properly positioning the patient so that unimpeded access is provided to the back of the arm.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Endoscopic Browlift Fixation with LactoSorb Screws

Friday, January 1st, 2016

 

Endoscopic Browlift Supraorbital Nerve Dissection Dr Barry Eppley IndianapolisThe most common surgical treatment today for sagging brows is the endoscopic browlift. As opposed to browlifts that involve long incisions and remove forehead or scalp tissue to create the lifting effect, the endoscopic technique uses minimal incisions and removes no tissue. It achieves a browlifting effect through a deep subperiosteal brow tissue release and a superior forehead and scalp backward tissue shift.

This relocation of the entire soft tissue of the forehead up and back, known as an epicranial shift, must be initially held in place to create the brow lift. A wide variety of endoscopic browlift fixation methods have been described since this browlifting technique was introduced about twenty years ago. Fixations methods including metal pins, metal screws, transosseous bone tunnels and resorbable grids or platforms. Each of these devices and methods have their advantages and disadvantages and the fact that so many endobrow fixation methods exist indicates that there is no perfect way to do it.

LactoSorb Endoscopic Browlift Screw Dr Barry Eppley IndianapolisHaving used all of these endobrow fixation methods, there is one that I found to be my favorite over the twenty years of performing the procedure. The use of LactoSorb resorbable screws offers a simple and very reliable soft tissue fixation method. This is a low profile 2.0mm screw made out of PLLA-PGA material which is naturally resorbed after 6 months of placement. It is a special resorbable screw that has a hole placed though its head and a pushpin design rather than that of a threaded shaft.

LactoSorb Endoscopic Browlift Drilled Screwhole Dr Barry Eppley IndianapolisLactoSorb Endoscopic Browlift Screw Suture and Lift Dr Barry Eppley IndianapolisThis fixation method issued by initially placing an outer cortical bone hole at the back end of the endo scalp incision. A suture is initially passed through the screwhead and then the screw is pushed into the bone hole. A snug fit allows the introducer for the screw to be removed. With the screw in place holding the suture, the uplifted scalp and forehead tissues are grasped with a bite of the suture and tied down. The overlying scalp incision is then closed.

Between the temporal lines of the skull, LactoSorb Endobrow resorbable screws can be used for central brow fixation. They are slightly palpable for a few months but their profile eventually flattens as they resorb over time. The time needed for natural fixation by healing of the elevated periosteum back down to the bone is reported to be a but a few weeks. So the months of fixation provided by the resorbable screw is more than adequate.

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.

Read More


Free Plastic Surgery Consultation

*required fields


Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories