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Technical Strategies – #10 Rib Removal Collapse Technique

Saturday, November 11th, 2017

 

Posterior rib removal is the end stage approach to horizontal waistline reduction. It removes the last anatomic barrier to a more narrow waistline after fat reduction by liposuction and muscle contouring by fascial plication in a tummy tuck. It creates this change in waistline profile by virtue of the angulation of the free floating ribs from their vertebral attachments. While often perceived as having a near horizontal or partially oblique orientation, these ribs are a lot more vertical orientation than most think. This places them in direct ‘obstruction’ with a more inward waistline movement.

While rib #s 11 and 12 are the classic free floating ribs and have no distal osteocartilaginous attachments, they are not the only ribs that can affect the waistline. Rib #10 above them also has a waistline effect. For this reason it is often included with rib #s 11 and 12 as part of the overall rib removal approach.

In such rib removal surgery it is important to center the small back incision needed over the middle rib to be removed. (#11) In his way the incisional access can be moved up or down to reach the neighboring ribs. While this works well for rib #12, rib #10 is often more challenging in this regard. Its higher ribcage position and the way it is angled makes it always the more challenging rib to remove. Coupled with the anatomic reality that the pleura of the lung always lies right beneath this rib, consideration of less than an aggressive reception of it comes to mind.

Rather the removal of the length of the rib, an alternative approach is to remove a small portion of the rib and allow it to collapse inward. Much like the arched span of a bridge, removal of the central portion of it can cause it to collapse inward or shorten. Removing a several centimeter piece of rib #10 can allow its outward curve to become less and achieve a somewhat similar effect with much less trauma and tissue damage than chasing the rib around to its subcostal attachments.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Temporal Artery Ligation

Monday, July 3rd, 2017

 

Temporal artery ligation is the only method to treat prominent arteries in the temporal and forehead area. An aesthetic condition that occurs almost exclusively in men, enlarged branches of the anterior superficial temporal artery develop as the arterial branches spread out after exiting the temporal hairline. In men who shave their head the arteries become apparent back in the temporal hairline. Unlike veins which may be treatable by laser or sclerotherapy, such is the not the case with the much higher flow artery.

Temporal artery ligation involves two basic steps, arterial pattern recognition and the actual ligation method. Vessel pattern recognition is extremely important and can be the more difficult of the two. Defining the ligation points to shut off both anterograde and retrograde flow is to ensure that the vessel is no longer seen and its flow and enlargement does not return later These ligation points have to be carefully evaluated and selected as the entire length of the vessels are not always seen. Palpation is often necessary to search for arterial pulsations.

The vessel ligation involves three considerations; 1) in situ or extracted ligation, 2) single or double ligation and 3) dissolvable/permanent sutures or vessel clips. The artery must be approached from very small incisions (5 to 7mms in length at most) as this is still an aesthetic procedure. It may be easier sometimes to pull the artery out of the incision for ligation rather than working inside a small ‘hole’. The strong muscular walls and vessel stretchability allow this to be done.

The exposed temporal artery can be singly or doubly ligated. When in doubt it is always better to tie it off twice for ligation security. Whether this is done with resorbable or permanent sutures can be debated. But if one is doing a single ligation then a permanent suture can be used. If it is a double ligation then resorbable sutures can be used. If small vessel clips are used a double application is just as easy as placing a single clip.

Dr. Barry Eppley

Indianapolis, Indiana

The Deep Pyriform Space Implant

Tuesday, July 19th, 2016

 

The nasolabial fold is a well known facial area that deepens with age. This has resulted in it being a common target for a variety of treatments that include injectable synthetic fillers and fat as well as the placement of subcutaneous implants. Regardless of the treatment they all are directed towards pushing out the linear skin indentation at the subcutaneous level.

pyriform aperture deep pyriform spaceIn recent anatomic studies the deep medial cheek fat compartment has a space deep to it known as Ristow’s Space. This has been described as a triangular paranasal area sitting right over the pyriform aperture. As a result of fat atrophy as well as bony resorption that occur with aging around it, Ristow’s space increases. Voluminization of this deep space has been proposed to be a new target in the treatment of the prominent nasolabial fold. The exact anatomic boundaries of this space, however, have never been precisely studied or defined.

In the July 2016 issue of Plastic and Reconstructive Surgery an article appeared entitled ‘Deep Pyriform Space: Anatomical Clarifications and Clinical Implications’. In this anatomic study the average dimensions of the deep pyriform space was essentially 1cm x 1 cm. The space has an inverted triangular shape that is bordered inferomedially by the depressor septi nasi muscle, the soft tissue attachments of the bony pyriform aperture and the retro-orbicularis fat. The premaxillary space and the levator labii superioris muscle sit above it. The angular artery lies superficial and lateral to the deep pyriform space.

The authors describe an injection technique to access this space for voluminization using blunt cannulas. With the cannula at the bone level the deep pyriform space is entered. They recommend very cohesive fillers like Radiesse or fat, presumably due to their better soft tissue push at this deep level, than hyaluronic-based fillers.

deep pyriform space implant dr barry eppley indianapolisThe deep pyriform aperture space is a midface cavity that is intimate to the pyriform aperture. It is accentuated by resorption of the face of the maxillary bone with aging. Pushing out on this space adds support to overlying cheek fat and lip elevators. Given the location of his space, it would intuitively seem like augmentation of the bone with an appropriately designed implant would provide a better long-term solution than any injectable filler.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Calf Augmentation

Wednesday, May 25th, 2016

 

chicken leg female calf augmentation Dr Barry Eppley IndianapolisBackground: A disproportionate lower leg size compared to the body, or even to the thighs, is often given the name ‘chicken legs’ This obviously refers to the very small size of the legs that most birds have compared to their bodies. While such a leg size is of no concern to birds, it can be quite disconcerting to some women. For those so afflicted, it is a source of embarrassment and may even prevent them from wearing any clothing that exposes their legs above the ankles.

A thin lower leg is usually due to small calf muscles. Underdeveloped calf muscles will make the lower leg between the knee and ankles look like a near straight pole without upper muscular bulging or shape. While there are two calf muscles per leg, both inner and outer gastrocnemius muscle are usually small. To make a visible size increase, all four heads or muscle bellies of the calfs need to be augmented.

Case Study: This 47 year-old female had been bothered about the small size of her lower legs for years. Because of her small calfs she would not wear shorts, dresses or any clothing that revealed her lower legs.

Calf Implant incisions Dr Barry Eppley IndianapolisCalf Implant subfascial location Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, 3.5 cm long inner and outer skin incisions were made in a popliteal skin crease above each calf muscle head. Through these incisions a subfascial pocket was developed on top of the gastrocnemius muscles. Small soft silicone calf implants were placed over each muscle head with two implants for each leg. (15cms long, 5cms wide and 1.5 cms thick)

Female Calf Augmentation result front Dr Barry Eppley Indianapolis viewFemale Calf Augmentation result back view Dr Barry Eppley IndianapolisFemale Calf Augmentation result raised back view Dr Barry Eppley IndianapolisFor many female calf augmentation patients, a four implant approach is needed. The goal is to make the overall calf size bigger without one side of the calf being disproportionate to the other side. By placing roughly 75cc implants on each muscle belly, or 150cc additional volume per leg, the calf is increased in size and still appears natural. For a small petite female these calf implants are appropriate. For larger female medium size calf implants (135cc per implant) may be needed.

Highlights:

1) Females with ‘chicken legs’ had small medial and lateral gastrocnemius muscles.

2) A four calf implant calf procedure is needed to treat the thin lower legs in female calf augmentation.

3) Four small incisions behind the knees is needed to insert subfascial calf implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Muscle Reduction Migraine Surgery

Sunday, July 19th, 2015

 

Background: There are a wide variety of types of headaches of which migraines make up some of the most disabling. While the exact cause of many migraine headaches is not precisely known, certain types of migraines are known to occur from peripheral compression of certain cranial nerves. This has led to a variety of injectable Botox and surgical decompression surgeries to treat these very specific types of migraines.

One the of peripherally-based type of migraine headache occurs in the temporal region or the side of the head. Because the temporalis muscle is a chewing muscle such headaches often occur in people who grind their teeth due to stress. The zygomatico-temporal nerve branch (ZTBTN) comes through the temporalis muscle near the eye and can often be a source of temporal migraines. Treatment with Botox injections (diagnostic test for surgical treatment or simple avulsion of the nerve can produce noticeable improvement in the frequency and duration of these type of temporal migraine headaches.

Temporalis Muscle Reduction and Augmentation Dr Barry Eppley IndianapolisBut a false Botox test of the ZTBTN nerve or failure to produce a very pronounced reduction in the migraine headaches indicates that the compression of this small sensory nerve is not the true source of the problem.  The overall size of the temporalis muscle and/or its repetitive contraction could then be more likely the headache source. This can be confirmed by a clinical examination of clenching of the teeth, feeling the expansion of the muscle and palpating for the location of the painful stimulus.

Case Study: This 56 year-old female had a long history of temporal headaches that had been refractory to every conceivable treatment. She knew that it came from clenching her teeth and was persistent on the side of her head. Dental splints, drugs and ZTBTN Botox injections did not provide relief. Botox placed all over the temporalis muscle provided some improvement but the dose requirement (50 units per side) was high and only temporary. (less than three months)

Temporal Reduction Dr Barry Eppley IndianapolisUnder general anesthesia, the posterior portion of her temporalis muscle was removed through a small vertical incision. Both the fascia and the muscle were removed anteriorly to about 3 cms behind the temporal hairline.

At one year after surgery, she reported a complete elimination of her migraine headaches. She did not have a single headache since the surgery. Her incisions healed inconspicously and she had no short or long-term effects on chewing or mouth opening.

Temporal muscle reduction may seem like a radical solution to the treatment of temporal migraines. But as an end treatment in the refractory migraine headache patient, it is a simple procedure that has no adverse functional effects.

Highlights:

1) Temporal (side of the head) migraines typically responds to Botox injections, ZTBTN nerve avulsion or ligation of the temporal artery.

2) When the source of temporal migraines is related to clenching and large bulging posterior temporal muscles, muscle reduction can be effective for which Botox injections would be the first treatment approach.

3) Temporal muscle reduction of its posterior belly is an end stage migraine treatment that can be effective in the properly selected patient.

Dr. Barry Eppley

Indianapolis, Indiana

PRP Injections for Periorbital Hyperpigmentation

Sunday, April 12th, 2015

 

Darkening of the eyelids, known as periorbital hyperpigmentation, is when excess pigment develops on the eyelids. While it can occur on either the upper and lower eyelids, and often involves both, it is most common and aesthetically troublesome on  the lower eyelids. Its causes is not exactly known and is multifactorial and has been ascribed to such events as sleep deprivation, smoking, alcoholism and excess sun exposure. Treatments for periorbital hyperpgmentation do not currently produce consistent nor uniform results.

In the March 2014 issue of the American Journal of Dermatology and Venerology, an article entitled ‘Treatment of Periorbital Hyperpigmentation Using Platelet-Rich Plasma Injections’ was published. Over a one year period, fifty (50) patients (almost all females) with periorbital hyperpigmentation were treated with PRP (platelet rich plasma) injection therapy. The periorbital area was injected with PRP for a total of three treatments spaced one month apart. The entire face was also injected at the same time. Using digital photos the results of these PRP treatments were assessed after six months from the last treatment. Very visible treatment was obtained in eight patients (16%), moderate improvement in twenty three patients( 46%) and minimal improvement in nineteen patients. (38%)

Periorbital hyperpigmentation, especially of the lower eyelids, is an aesthetic problem that defies one single effective solution. It is seen most commonly in patients who have significant skin pigmentation. Many treatments have been advocated for it from topical skin bleaching, laser resurfacing and light therapies, injectable fillers, fat injections, orbital rim augmentation and lower blepharoplasty skin tightening. While effective in some cases, there is no treatment that is universally effective for everyone. Getting excess pigment out of the skin is difficult without risking injury to the skin that contains it.

PRP injections Indianapolis Dr Barry EppleyThe biologic basis for the development of excess pigment on the eyelids has been suggested to be due to chronic edema and lymphatic congestion which causes a hyperpigmentation response. Improving the vascularity of the eyelids tissues is thought to potentially improve lymphatic outflow and allow for pigmentation reduction. This would be the potential mechanism for why PRP would produce an improvement in the eyelid hyperpigmentation. This plasma suspension obtained from processing the patient’s whole blood has a high concentration of platelets which contain high levels of growth factors. These are well known to produce healing responses marked by increased vascularization. and improved tissue perfusion levels. This may the mechanism for the clinical improvements seen in this study.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Cellfina for Cellulite Treatment

Thursday, April 2nd, 2015

 

Cellulite AnatomyCellulite is a very common aesthetic problem for women (and a few men) that has defied an absolute solution for many decades. The number of externally applied creams, lotions and massage approaches speaks to the fact that a successful non-surgical approach remains wanting. Numerous surgical approaches have also been used that focus on either releasing the vertical fascial bands and/or fat reduction that makes up the well known anatomy of celulite.

With over a billion dollars a year spent on treatments for the well recognized ‘cottage cheese’ thighs and buttock problem, the search for the next promising cellulite treatment is always ongoing. The new cellulite treatment introduced this year will be Cellfina. (Ulthera

Cellfina Procedure for Cellulite Dr Barry Eppley IndianapolisCellfina is a minimally invasive procedure whose objective is to release the vertical fascial bands. Under local anesthesia a vacuum-assisted tissue release is done to break up these bands. A small rotating blade introduced under the skin cuts the band and the vacuum pressure on the skin creates the complete release. It is purported to be a one-and-done procedure with results visible within a few days after the procedure and its effects last at least a year. The clinical trial studies report that some results can last for as long as three years. Clinical studies show a high patient satisfaction rating at 94% after one year.

Treatments take less than one hour to complete and Cellfina treatment costs range from $2,000 to $5,000 based on where one is located in the U.S. as well as how many cellulite areas are treated. Expect Cellfina devices to be more widely available later this year.

Dr. Barry Eppley

Indianapolis, Indiana

Stem Cells and Fat Injections in Plastic Surgery

Tuesday, January 20th, 2015

 

Just recently the Food and Drug Administration (FDA) has approved a private company’s (Antria) Phase 2 clinical trial study for the use of fat-derived stem cells in plastic surgery. These trials are set to begin within the next three months. Antria received approval for Phase 1 clinical trials just under two years ago in March 2013.

Stem Cells and fat Injections Dr Barry Eppley IndianapolisAntria is the first company in the world to obtain FDA approval for human studies for stem cell-assisted facial fat grafting study. Antria’s patent-pending process uses liposuction to extract the fat. Within one hour, stem cells can be prepared from that fat. Antria’s process uses its proprietary Adipolyx solution, a collagenase-based reagent, to isolate stem cells from adult fat cells.

While this FDA approval is significant in and of itself, the even greater relevance is what this indicates for the widespread marketing of so-called stem cell procedures in plastic surgery. The reality is that there are really no true stem cell procedures in plastic surgery despite what is claimed or promoted on the internet and otherwise. Procedures touted as ‘stem cell-enriched’, ‘stem cell injections’ or ‘stem cell procedures’ in plastic surgery are misleading.

While fat does contain numerous stem cells, these are inadvertent passengers in what is otherwise and simply put fat injections. Extracting fat by liposuction and concentrating it for injection for soft tissue augmentation does not make it a bone fide stem cell treatment. This is a marketing tactic, which although very appealing to patients, implies properties of the injection treatment that it does not have.

fat injections to forehead dr barry eppley indianapolisFat injections have many benefits from adding soft tissue volume to improving the vascularity of the injected tissues. But whatever role the percentage of stem cells in the fat has in these benefits is highly speculative. That should not he confused with a highly concentrated and pure source of stem cells which is what is currently being studied in human clinical trials

Dr. Barry Eppley

Indianapolis, Indiana

World of Plastic Surgery – Iceland

Monday, January 12th, 2015

 

Iceland Plastic Surgery Dr Barry Eppley IndianapolisIceland is a nordic island located between the North Atlantic and Arctic seas. With a small land mass of around 40,000 square miles and a population of just over 300,000, it is the most sparsely populated country in all of Europe. The vast majority of the population lives along its coasts with two-thirds of it being located in the capital city area of Reykjavik in the southwest region of the country. The interior is largely uninhabited being a plateau covered by mountains, lava fields and  glaciers.

Iceland has one medical school and basic postgraduate training is for medical licensure in the country. But speciality training in plastic surgery must be obtained overseas usually in the United Kingdom, Sweden or other European countries. There are only a handful of plastic surgeons in Iceland, all of whom seem to be located in Rekjavik which is the largest city by far. Of the thirty-two identified towns, cities or municipalities in the country only six have a population greater than 10,000 of which five are in the Capital Region. So it is no surprise that there is were the few plastic surgeons are.

Iceland has nationalized health so reconstructive plastic surgery is done through that system. Most aspects of major reconstructive plastic surgery seem to be available. Cosmetic plastic surgery is as available in Iceland as any other European country or the U.S.. The cost of Icelandic cosmetic surgery is definitely lower than in the U.S.. While the currency of Iceland is the Krona, cosmetic surgery prices are generally available in Euros. Typical costs quotes are 2,700 Euros for breast augmentation, 2,670 Euros for rhinoplasty and 3,500 Euros for a facelift for example. Converting Euros to dollars shows that most cosmetic surgery costs are about 25% to 33% less than in the U.S.

Dr. Barry Eppley

Indianapolis, Indiana

Joan Rivers – A Comedian’s Legacy to Plastic Surgery

Thursday, September 11th, 2014

 

Joan Rivers and Plastic Surgery Dr Barry Eppley IndianapolisJoan Rivers, comedian and and, in many ways, a champion of plastic surgery, died last week…ironically, having a minor surgical procedure. (however, not a plastic surgery procedure). She is the second such famous female comedian (Phyllis Diller in 2012) that has been tied to plastic surgery that has died in the past few years; both of them pioneering female comedians and both more than willing to make endless jabs at their own adventures in surgical self-improvement.

No one knows exactly how many plastic surgery procedures Joan Rivers had. Most likely her jokes about them far exceeded what she had done. (minus Botox Cosmetic which does not count as actual surgery). Some of her most well known quotes on plastic surgery include:

‘I’ve had so much plastic surgery, when I die they will donate my body to Tupperware.’

‘I wish I had a twin, so I could know what I’d look like without plastic surgery.’

‘I have flabby thighs, but fortunately my stomach covers them.’

‘I’m never without a bandage.’

‘I’ve had so much Botox Betty White’s bowels move more than my face.’

‘I saw what’s going on under my chin. I don’t want to be the one the president has to pardon on Thanksgiving.’

‘The only way I can get a man to touch me at this age is plastic surgery.’

‘Every weekend I just go in and I do something….You get a tenth one free. It’s like coffee so you just keep going’

‘I was so ugly that they sent my picture to Ripley’s Believe It or Not and he sent it back and said ‘I don’t believe it’.’

‘Better a new face coming out of an old car than an old face coming out of a new car’.

What Joan Rivers (and Phyllis Diller) are most famous for about their plastic surgery is not their quotes but how they were perceived as classic examples of everything that is ‘wrong’ about having plastic surgery. She was commonly referred to as what patients would say they did not want to look like…over done and unnatural. But such criticism is a bit harsh since at age 81 she looked awfully good and much better than what the natural aging process had to offer.

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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