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Plastic Surgery
Dr. Barry Eppley

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

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

December 13th, 2015

Case Study – Breast Implants and Tattoos

 

Background: Placing implants to increase breast size is the most common surgical method of breast enhancement. The most common non-surgical method of breast enhancement are tattoos. When it comes to breast tattoos, there is an endless variety of patterns, sizes and colors. From words to images to some incredible artistic patterns, breast tattoos are as individual as the patient themselves. While most breast tattoos are fairly small, some of very large and can even cover the entire breast mound.

As breast implants enlarge the breast mound some enlargement of the existing tattoos is likely to occur. The closer it is to the center of the breast mound the more the tattoo will increase in size. But rarely does it ever distort the tattoo that it is not longer appealing.

Case Study: This 35 year female came in for breast augmentation. Across her sternum on the lower half was large inverted moth tattoo. The lower body of the moth;’s wings were on the inner lower portion of the small breast mound.

Moth Breast Augmentation results front viewMoth Breast Augmentation result oblique viewUnder general anesthesia 450cc high profile smooth round silicone gel breast implants were placed through inframammary incisions. The implants enlarged the breast mounds to the desired size and gave the back wings of the moth tattoo a ‘lift’ as well,

There are no contraindications to getting breast implants with any form of a tattoo on the breast mounds. The tattoo may change slightly with a modest increase in its size as would be expected.

Highlights:

  1. Some women that present for breast augmentation have a multitude of tattoo sizes and patterns in their breast mounds.
  2. The incisions to insert breast implants rarely disturb breast mound tattoos.

3) Some tattoos may increase in size some what as the breast mounds get larger due to the placement of breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

December 13th, 2015

Hand Rejuvenation by Fat Injections

 

Aging affects every structure of the body and the hands are no exception. Age-related changes to the hands have been well described and includes thinning of the skin, brown spots and wrinkles and visible skeletonization with prominent veins, tendon and bone structures. Loss of fat volume is one of the key features in hand aging just as it is in the face.

Fat Injections to Hands Dr Barry Eppley IndianapolisIt is no surprise then re-voluminization of the dorsal side of the hand has become an established ant-aging strategy in hand rejuvenation. Fat is preferred over the use of injectable fillers due to its better volume retention and ultimately lower cost in the long run. It also has the potential benefits of providing improved skin tone and texture through dermal regeneration induced by blood vessel ingrowth and stem cell effects.

In the December 2015 issue of the journal Plastic and Reconstructive Surgery, an article entitled ‘Technical Refinements in Autologous Hand Rejuvenation’ appeared. In this paper the authors describe their technique for fat injections into the dorsum or back of the hand. Fat is harvested from the inner thighs. Approximately 20 to 25mls of aspirated fat is required for each hand. A central injection point is used located between the 3rd and 4th metacarpal joints. Fat is injected in a radiating fashion in the subcutaneous plane using about 10 to 15mls in the distal two-thirds of the hand to augment the region dorsal to the hypothenar eminence. A second injection site is done from between the first and second metacarpals where an additional 10mls of fat is injected into the proximal one-third of the hand  to augment the region dorsal to the thenar eminence. They have experienced no complications such as infection or any problens with hand function or sensation.

Fat injections into the hands places the grafts into the dorsal superficial lamina, the upper fascial  where the fat normally resides. The fascia that contains the veins and nerves lies deep to this layer. The deepest fascial layer is where the tendons and bones reside. Placing fat into the hands is easy as placing it right under the skin keeps it in the upper fascial layer and avoids the visible veins which seems like they would be unavoidable. The use of blunt cannulas avoids any risk of vein puncture. The injected fat must be massaged around to avoid lumps and irregularities. Aggressive and persistent massage is the key to a smooth fat distribution.

Fat Injections to the Hands Dr Barry Eppley IndianapolisWhile the authors inject from the distal part of the hand (metacarpal joint areas), I prefer to inject from the proximal area at the wrist. Three injection site are used  and the fat is placed in a retrograde fashion. The ability to distribute the fat by massage throughout the upper fascia layer of the hand makes the location of injection irrelevant.

Total hand rejuvenation requires both an internal and an external approach. Fat grafting treats the intrinsic problem of aging by restoring/adding volume. But the external appearance of the hand should not be forgotten and treatments such as laser resurfacing and pulsed light therapy (BBL) should not be overlooked for optimal improvement in the appearance of the back of the hands.

Dr. Barry Eppley

Indianapolis, Indiana

December 12th, 2015

Case Study – Subnasal Lip Lift and Mouth Widening Surgery

 

Background: A full upper lip and a broad smile are several mouth features that are associated with youth and attractiveness. While there are a variety of lip enhancement procedures, the lip lift represents just a minority of the cosmetic lip procedures done. Its largely hidden subnasal scar location and the visible upper lip shortening effect give it a limited but defined role in lip enhancement options.

Less has been described about how to manage a ‘small mouth’. A short horizontal distance between the corners of the mouth is often perceived as the width of the mouth that lies within vertical lines dropped down from the pupils of the eyes. Many have asked about how to widen their mouth but have been discouraged from doing so because of concerns about adverse scarring. But cosmetic mouth widening surgery should not be confused with the corner of mouth reconstruction that is done in cases of congenital or traumatic microstomia.

Case Study: This 22 year female wanted to shorten her long upper lip and get more of a prominent cupid’s bow appearance. (the philtral distance was 18mms in length)  In addition she wanted to have more upper tooth show at the bottom of the upper lip smile line. She also felt that the width of her mouth from corner to corner was too small and wanted it widened.

Subnasal Lip Lift and Mouth Widening Procedure design Dr Barry Eppley IndianapolisSubnasal Lip Lift and Mouth Widening Procedure immediate result front view Dr Barry Eppley IndianapolisUnder local anesthesia in the office, a bullhorn pattern skin excision was marked out under the base of the nose and removed. An excisional skin width of 5.5mms was made along the philtral columns, making it almost one-third of the upper lip length removed. At the same time an arrow-shaped segment of skin was removed from outside the corners of the mouth. (horizontal length of 5mms removed on each side) The mucosa at the corners of the mouth was mobilized and brought out to a new corner of mouth position. This created a 1 cm increase in horizontal mouth length.

Subnasal Lip Lift and Mouth Widening Procedure immediate result side view Dr Barry Eppley IndianapolisA subnasal lip lift creates a shorter upper lip which is often associated with a younger appearing upper mouth area. Short mouth widths can be increased by moving the location of the outer corner of the mouth mucosa. (mouth widening procedure) A subnasal lip lift and lateral commissuroplasties can be done at the same time.

Highlights:

  1. The subnasal lip lift accentuates the central part of the upper lip vermilion (cupid’s bow) by shortening the vertical distance of the skin below the nose.
  2. A short horizontal mouth distance can be increased by a lateral commissuroplasty procedure which opens up the corners of the mouth.

3) A subnasal lip lift and mouth widening surgery can be done together for a more complete perioral change.

Dr. Barry Eppley

Indianapolis, Indiana

December 10th, 2015

The Preperiosteal Cheeklift

 

Rejuvenation of the aging lower face is done well by classic facelift techniques.  And rejuvenation of the upper face is also done well by traditional browlift and blepharoplasty surgery. But the intervening middle of the face, the cheek area, is far more difficult to treat with surgical rejuvenation methods due to surgical access and the facial nerves which run through the cheeks.

Cheek aging is seen by the development of eye bags, tear troughs, a prominent lid-cheek line or junction and the overall sagging or decent of the cheek tissues. A wide variety of cheek lift procedures have been described and most employ a subperiosteal approach through a lower eyelid incision. This is popular because it is a safe plane of dissection being below the level of where buccal branches of the facial nerve may lie.

preperiosteal cheekliftIn the December 2015 issue of the journal Plastic and Reconstructive Surgery, an article appeared entitled ‘Midcheek Lift Using Facial Soft Tissue Spaces of the Midcheek’. In this paper the authors describe a preperiosteal midcheek lift technique that uses the micheek soft tissue spaces by precise release of its retaining ligaments that separate the spaces. Through a lower subciliary eyelid incision, a skin only lower eyelid flap is raised. This allows the orbicularis muscle to be used as a source of suspension. Through a window into the suborbicularis muscle plane blunt dissection is carried into the preseptal space. From this space dissection is carried into the premaxillary space where the tear trough ligament can be released. Out laterally release of the orbicularis retaining ligament allows entrance into the prezygomatic space where the zygomaticofacial nerve exiting from the bone is seen. Dissection is carried in this plane up to the lateral canthal region. This dissection connects the three soft tissue spaces of the midcheek, the preseptal, premaxillary and prezygomatic spaces. Opening up these spaces allows the overlying orbicularis muscle to be used as a source of traction and suspension for the entire midcheek. The muscle is suspended to the periosteum of the lateral orbital rim to create the cheeklift. Canthopexy was done for lower eyelid support.

Over a five year period, a total of 184 patients were treated with this cheeklift technique. The vast majority of patients (96%) were satisfied with the procedure. A significant rejuvenation of the cheek with elimination of eye bags, elevation of the lid-cheek junction and the cheek prominence and improvement in the depth of the nasoabial folds were seen. Ectropion only occurred in 1% of the patients. Lid retraction occurred in 2% of the patients. Prolonged chemosis occurred in 4% of the patients.

This cheeklift technique goes above the periosteum as opposed to below it as is traditionally done. It is a safe dissection that can be done rapidly and mobilizes the cheek tissues using  the soft tissue spaces between the retaining ligaments. Like all cheeklifts the risk of lower eyelid malposition and etropion can occur. Prevention through lateral canthopexies and avoiding to much lower eyelid skin removal is important.

Dr. Barry Eppley

Indianapolis, Indiana

December 8th, 2015

Case Study – Female Subnasal Lip Lift

 

Background: There are a variety of upper lip enhancement procedures from injectable fillers to lifts. By far lip lifts represent just a minority of cosmetic lip procedures done and, as a result, is a frequently misunderstood operation. A subnasal lip lift can be confused with a lower lip advancement because they are both excisional procedures. But a lip lift truly does lift the lip up while a lip advancement pushed up the vermilion from below.

The appeal of a subnasal lip lift is that the scar rests in a relatively concealed area along the base of the nose. When performing the procedure it is important to recognize that the interface between the base of the nose and the lip is not a straight line. It is a multiply curved interface hence the urban name for a subnasal lip lift…the bullhorn lip lift. But despite the appeal of the scar location, a lip lift has its limitations and it is important that patients understand what they are before undergoing to the operation.

By removing skin from under the nose, the vertical distance of the upper lip is effectively shortened. That is its primary effect and by so doing there will be an increase in the fullness of the cupid’s bow vermilion. But beyond the centrally located cupid’s bow the vermilion along the sides of the lip will not change. Draw a vertical line down from the sides of the nostrils and any part of the lip lateral to it will be unaffected by a lip lift. Also, contrary to popular perception, a lip lift will not increase upper tooth show. That area is simply too far away from the point of pull to be affected. To improve tooth show at the time of a subnasal lip lift, a lower horizontal vermilion excision is needed at the same time.

Case Study: This 44 year female felt she had a long upper lip and wanted it shortened. She also wanted the lip lift to look natural and not be overdone. The length of the upper lip along the philtral columns was 18mms.

Cali Lip Lift results front view Dr Barry Eppley IndianapolisCali Lip Lift results oblique view Dr Barry Eppley IndianapolisUnder local anesthesia, a bullhorn pattern of skin excision was marked under the base of the nose and removed. An excisional width of 4.5mms was made along the philtral columns, making it 25% of the total upper lip length. At three months after the procedure the subnasal scar redness is fading nicely and the stability of the lip lift maintained at 14mms of philtral column length.

Cali Lip Lift results side view Dr Barry Eppley IndianapolisA subnasal lip lift has a central upper lip effect that is limited to the skin component area of the prolabium. The skin distance of the upper lip is reduced and the cupid’s bow is more pronounced. But the sides and bottom area of the central upper lip remained unchanged.

Highlights:

  1. A lip lift is a lip shortening procedure that affects the central part of the upper lip only.
  2. A well placed subnasal lip lift scar curves in and around the nostrils and columella and is not a straight line.

3) A subnasal lip lift will usually not increase upper tooth show and will not increase the fullness of the sides of the lip.

Dr. Barry Eppley

Indianapolis, Indiana

December 7th, 2015

Plastic Surgery Humor – The Redistribution Effect

plastic surgery redistribution effect

Part of many procedures in plastic surgery create a redistribution effect. For example a facelift relocates sagging tissues from the jowls and neck and moves them back up into a better place. Rhinoplasty takes down a hump and lifts up a low tip. A Mommy Makeover makes the breasts bigger and perkier with tightening and narrowing the waistline. These are just a few examples of how plastic surgery just ‘changes things around’ for a better aesthetic appearance.

Another part of these redistribution efforts is that tissues may also be removed from one area and relocated to another. Historically this is known as grafting and is part of many aesthetic and reconstructive plastic surgeries. A classic example would include cartilage grafting in rhinoplasty from the septum, ear or ribs. The most contemporary example of the redistribution principle in plastic surgery, and one with very wide broad application, is that of fat grafting. Fat can be harvested from a large number of donor site options and placed by injection into any facial or body area that one desires to be augmented. Facial fat grafting is done for a variety of rejuvenative procedures such as lip and cheek augmentation and done with facelift surgery . Augmentation of the breasts and buttocks is very popular as the appeal of using one’s own tissues, and get a simultaneous slimming effect from the harvest, creates a dual benefit.

As this cartoon implies, many people have undesirable things in one body area that would do much better if it was relocated to another body area. Plastic surgery can be seen to have a broad redistribution effect.

Dr. Barry Eppley

Indianapolis, Indiana

December 7th, 2015

Male Facelift Incisions

 

Facelift surgery is the most effective method for reshaping the aging neck and jawline. While many variations of facelifts exist, each with their own advocates, it is clear that there is no single one best way to perform the surgery. The extent of skin undermining, how the underlying SMAS layer is manipulated and what other procedures are done with the facelift, (e.g., fat injections, cheek and chin implants) dominate the talk about facelift surgery. And while each of these maneuvers has their own merits, the most important outcome of a facelift is whether it is detectable as having been done.

The most distinguishing markers of having had a facelift are the incisions around the ear and whether the hairline around them looks undisturbed. Thus the placement of the ear incisions and how the hairline is managed determines whether the facelift is detectable or not. Visible incision placement, wide scars, distorted earlobes and stepoffs in the temporal or occipital hairlines are assured indicators of surgical manipulation and detectability.

While much of a facelift procedure is the same regardless of gender, the one clear difference is in how the incisions are managed. Beard skin and shorter hairstyles are what makes facelift incisions between men and women potentially different. While the retrotragal preauricular incision (behind the tragus in the front of the ear) is the standard for women, beard skin in men requires more thought for the location of this preauricular incision.

Male Facelift Scars Dr Barry Eppley Indianapolis 2Because of the location of the back of the beard hairline near the ear (usually about 1 to 1.5 cms in front of the ear) the choice of either a completely preauricular or partial retrotragal incision influences where the beard skin ends up. The safest way to prevent hair-containing skin from ending up on the tragal skin and inside the ear is to use a completely preauricular incision.This does lose the normal non-hair bearing skin between the ear and the beard skin but at least keeps it off the ear.

older make facelift scarThe other approach to the male facelift incision is to use the same incision as in females. (combined preauricular-retrotragal) This will effectively hide the incision line behind the tragus. But keeping the hair off the tragus is a function of the direction of the undermined skin pull. In men the movement of the skin pull should be largely vertical resulting in some preservation of non-hair bearing skin that ends up being pulled onto the tragus. This is in contrast to a more oblique and posterior skin pull in females who can afford to do so because of their lack of any beard skin.

Besides the aesthetics of the incisional healing around the ears, the placement of male facelift incisions also influences the neck and jawline changes as well. Less dramatic changes in the neck often result in male facelifts because of the care taken to have good incisional healing and displacement of the beard skin onto the ear.

Dr. Barry Eppley

Indianapolis, Indiana

December 6th, 2015

Kybella Injections for Jowls

 

The search to non-surgically reduce fat for aesthetic purposes has been ongoing for years and many methods exist today to do so. Numerous energy-based devices are available (e.g., Vanquish) for body contouring which induce fat cell atrophy through an apoptosis process. But such devices have limited use in the face due to the smaller fat collection locations and the difficulty with such device application.

Kybella Injections Dr Barry Eppley IndianaolisFat dissolving injections have recently become available based on the introduction of deoxycholic acid solutions.  (Kybella) This chemical causes the dissolution of fat cell walls which release their lipid contents into the surrounding tissues. The free fatty acids are then absorbed from the injected area reducing the treated contour. Kybella injections have been clinically tested and FDA-approved for the treatment in the head and neck area of the submental area. Known as the double chin neck deformity, the smaller submental area is a good location for the use of fat dissolving injections in properly selected patients.

Kybella Injections for Jowls result right oblique view Dr Barry Eppley IndianapolisKybella Injections for Jowls result front view Dr Barry Eppley IndianapolisKybella Injections for Jowls result oblique view Dr Barry Eppley IndianapolisOther facial areas can potentially also benefit from Kybella injections for small fat reductions. One such area is that of the jowls. The jowls are an area along the jawline which develop from the descent of facial tissues with aging. Skin and any underlying fat drifts down over the jawline creating the classic jowling and increased lower facial width. While fat reduction alone is not the complete solution to jowls in most patients, it is one component whose reduction can help reduce their appearance.

Kybella injections to the jowls works identically to that of the submental area. It requires a series of injection treatments spaced four to six weeks apart. Two to three injection sessions may be needed for optimal reduction. The jowl area is smaller than the submental area so a lower number of injections are needed. There will still be considerable swelling after the injections for the first week due to the inflammatory process of how the solution breaks down the fat cells.

Because fat injection therapy can be done just about anywhere, Kybella will continue to evolve in both its face and body applications.

Dr. Barry Eppley

Indianapolis, Indiana

December 6th, 2015

Case Study – Macrotia Ear Reduction

 

Background: The embryology and development of the human ear is a marvel in not only its complexity but how well it works most of the time. It is created by the merging of six separate tissue segments (hillocks) in utero that create the recognizable ear that is a collection of various ridges and valleys. But due to its complex shape the ear is prone to a wide variety of congenital anomalies of which microtia is the most severe.

macrotiaThe opposite of microtia is macrotia where the ear is abnormally large. Unlike microtia where various parts of the ear are either missing or deformed, in macrotia the ear components are normal but bigger than desired. The ear is usually felt to be large primarily because it is vertically long. Various parts of the ear may be bigger than normal but usually the upper and lower thirds of the ear are what is too long.

The average height of the ear, as measured from the bottom of the lobule to the top of the upper helix, is in the range of 60 to 65mms. (average of 63mms) While they are some slight differences in these measurements between men and women, they are not all that different. (around 5% or less) The average length of the earlobe is around 18mms or about 1/3 of the total ear height.The average height of the pinna or cartilaginous portion of the ear, calculated by subtracting the earlobe height from the total ear height, was around 45mms.

Case Study: This 27 year male had ears that he felt were too big (long) as well as stuck out. He had seen other plastic surgeons but they only wanted to fix the protruding aspect of them. His total ear height was 76mms with an earlobe length of 24mms.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder local anesthesia with infiltration around the base of his ear, three specific ear reshaping procedures were done. The earlobe was vertically reduced by 6mms with a helical rim excision technique. The upper third of the ear was reduced by 7mms using  scaphal excision of cartilage and outer skin with a helical rim reduction. (scapha-helical rim flap) Lastly ear was set back with concha-mastoid sutures from a postauricular incision. At the end of the procedure the total ear height was 65mms.

Macrotia ear reduction is done by reducing the height of the ear from the top (scapha-helical reduction) and bottom (earlobe reduction) simultaneously. Correction of any ear protrusion can be safely done during macrotia reduction surgery.

Highlights:

  1. Macrotia is an aesthetically abnormal enlargement of the ear that is most manifest in the vertical dimension.
  2. Macrotia ears usually have a combined increased height of the upper ear and longer earlobe.

3) Macrotia ear reduction surgery is done by an upper ear scapha-helical reduction flap and a helical rim earlobe reduction.

Dr. Barry Eppley

Indianapolis, Indiana

December 6th, 2015

Case Study – Custom Silicone Testicular Implant Replacement

 

Background: Replacement of a undeveloped or removed testis can be done with the placement of a testicular implant. The history of testicular implants goes back well over fifty years and has included a variety of material compositions. The most satisfying device became the silicone gel-filled testicular implant due to its feel. But like silicone breast implants, it went into exile when the FDA pulled silicone breast prostheses off the market in the early 1990s.

saline testicular implants dr barry eppley, indianapolisTo create a viable device for the men who would benefit by a testicular implant, saline filled testicular implants became clinically available in 2002. Today they remain as the only FDA-approved testicular implant. The outer shell or bag of the implant is made of a thin silicone but it is filled with with a saline solution at the time of surgical implantation. It comes in four different sizes with implant volumes ranging from extra small to large.

While the saline testicular implant is stated to have about the same weight, shape and feel of a normal testicle, not all men say that it feels similar to their opposite normal testis. A saline testicular implant in some men can feel more firm as it is less compressible due to the saline water being under tension. This is not unlike how an overfilled saline breast implant may feel to some women

Case Study: This 60 year male had a left saline testicular implant placed one year after his original testis was removed due to infection. He did not like the size and feel of the implant from the very beginning. It felt too hard and was only about half the size of his normal right testis. A new custom testicular implant was made from a very low durometer silicone material and was designed by taking caliper measurements of his right testis. The custom implant measured 57mm long by 42mm wide. By feel it was very ‘squishy’ and easily compressible.

Saline vs Silicone Testicle Implant Dr Barry Eppley IndianapolisUnder general anesthesia. his old high scrotal incision was reopened and the saline implant removed. The scrotal sac was inverted and the existing capsule was scored so the implant pocket would stretch out to contain a testicular implant that was 50% larger. The new custom silicone testicular implant was then inserted and scrotal opening closed in three layers with resorbable sutures for the scrotal skin.

Testicular Implant Replacement immediate after result Dr Barry Eppley IndianapolisThe improvement in the scrotal sac symmetry was immediate with an increased lowering and fullness to the left scrotal side. By size and feel it felt much more like his right testis.

A custom silicone testicular implant can be an improved option for an existing saline testicular implant that is not big enough or feels too firm.

Highlights:

1) Saline testicle implants can potentially feel unnaturally hard and may be undersized for some men

2) A smooth and soft solid silicone testicle implant can feel more natural than a saline testicle implant.

3) For a larger sized testicle, a custom made silicone testicle implant can be made and used for either primary placement or for replacement of an inadequate saline testicle implant.

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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