EXPLORE
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.

August 26th, 2015

Case Study – Custom Parasagittal Skull Implants

Background: The top of the skull has the best aesthetic shape when it is a smooth convex curve from one temporal line to the other. This shape can be altered and is influenced by the original sagittal suture line which runs down the middle of the skull between the two original anterior and posterior fontanelles. While it should be smooth and unraised sagittal crest deformities can occur which can be argued are very minor variants of the well known sagittal craniosynostosis condition.

A sagittal crest can develop which appears as a prominent bony ridge down the middle. This can make the bony area between the temporal lines at the side and the midline of the skull (parasagittal area) appear depressed or too shallow. It is also possible that the height of the midline of the skull is normal but that the bony problem is that the parasagittal region is underdeveloped. Either way the top of the head does not have a convex shape and appears irregular in contour.

To create a more convex shape to the top of the head, it is necessary to determine whether sagittal crest reduction needs to be done or parasagittal augmentation is more appropriate.  Computer imaging from the frontal view is very helpful in this regard although there are limitations to it based on the length and density of one’s hair.

Case Study: This 24 year old male wanted to improve the shape of the top of his head. He felt that he had two grooves on each side of the middle of the skull running from front to back. While they were not big or severe they were bothersome to him. He felt that the height of the middle of his skull was fine and it was the sides along it that were too deep.

Parasagittal Skull Implant Designs Dr Barry Eppley IndianapolisParasagittal Skull Implant Thicknesses Dr Barry Eppley IndianapolisUsing a 3D CT scan custom parasagittal skull implants were designed to fill in the grooves. They were long and slender and spanned the traverse from the midline to the temporal region on both sides. With the aid of computer design the parasagittal depressions were filled up just to the level of making the temporal lines curve upward to the midline and nothing more.

parasagittal skull implantsPerforated Skull Implants Dr Barry Eppley IndianapolisScrew Fixation of Parasagittal Skull Implants Dr Barry Eppley IndianapolisUnder general anesthesia two small (3 cm) incisions were made at the posterior end of the parasagittal region near the back of the head. Subperiosteal tunnels were made and the implants inserted. Once positioned they were secured with a single 1.5mm self-tapping titanium screw.

Parasagittal grooves or depressions can be augmented to help create a more convex head shape across the top. Given their small size in many cases and the need for perfectly smooth edges that lay flush to the surrounding skull bone, a custom computer-designed implant approach is needed. This also allows the skull implants to be inserted through the smallest possible scalp incisions with assurance that they will create the best possible contour result.

Highlights:

1) Parasagittal skull deficiencies can occur due to either a high sagittal crest, low parasagittal areas or both.

2) Correction of low parasagittal areas of the skull is done by augmnetation to bring them closer to the level of the sagittal crest.

3) Custom parasagittal skull implants are the most accurate and least invasive method to augment long slender skull deficiencies.

Dr. Barry Eppley

Indianapolis, Indiana

August 26th, 2015

Chin Implant Imprinting

 

The use of a chin implant for an increase in lower facial projection is often combined with other procedures (e.g., rhinoplasty) as well as done as an isolated chin augmentation. It has a long history of use in aesthetic facial surgery dating back over fifty years and nearly every available biomaterial has been tried as some form of a chin implant. But the use of silicone chin implants today constitutes the majority of chin augmentation devices used.

One phenomenon of placing a silicone chin implant (it also occurs with other biomaterials as well) is that of ‘chin implant erosion’. This is an erroneous term that implies that a chin implant is actively eating into or destroying the chin bone underneath it. (aka an active inflammatory process occurring as a a result of a bone reaction in response to a leaking of silicone molecules from the implant) That perception and propagated term is far from what actually occurs.

Chin Implant Imprinting 3 Dr Barry Eppley IndianapolisThe chin is a unique facial area for augmentation because it is a projecting bony structure with tight tissue attachments that wrap around it. Thus when an implant is placed between the chin bone and the overlying soft tissues it will exert some forces (pressure) on the underlying and overlying soft tissues. The body will relieve this pressure with passive adaptation to it. Since the chin implant can not change due to its synthetic inert structure, the surrounding tissue must. As a result, the chin implant will often (although not always) settle a millimeter or two into the bone as a form of pressure relief. This can be seen in great detail as the serial number, size indicator or any grooves or markings on the implant can be seen on the bone surface as the implant is removed.

Chin Implant Imprinting Dr Barry Eppley IndianapolisThis passive bony remodeling phenomenon to a chin implant is benign and self-limiting. It has little to no impact on the external aesthetic chin augmentation result and does not affect the quality of the underlying bone. Because most chin implants are placed in the subperiosteal plane this settling will also allow some bony growth to often extend up along the sides of the implant. Such bony overgrowth can be seen clearly intraoperatively as well as on CT scans. This bony overgrowth further implies that the implant is not causing a destructive bony process.

There are very rare cases where chin implant settling has placed the mandibular incisor tooth roots at risk or has caused some dental sensitivity. This is a direct result of a chin implant being placed far too high over the much thinner cortical bone near the tooth roots. As a result, passive implant settling may occur deeper into the bone and appear very close radiographically to the tooth roots. This is the direct result of an incorrect chin implant placement.

It is time to eliminate the term ‘chin implant erosion’ due to its biologic inaccuracy and replace it with a term that correctly identifies it with the passive bony remodeling process that it is. The better descriptor would be ‘chin implant imprinting’.

Dr. Barry Eppley

Indianapolis, Indiana

August 26th, 2015

Case Study – Large Nose Female Rhinoplasty

 

Background: Rhinoplasty can achieve many different types of nasal changes. The classic requested changes would be reduction of a prominent hump or bump and making the tip smaller, more refined and usually shorter. Straightening of a crooked nose is also a common request and is done as part of any other nasal shape change. These type of rhinoplasty changes are the same whether one is male or female.

Women may have rhinoplasty surgery to achieve a number of specific changes including a smaller and more upturned nose, hump removal and thinner straighter nose. Often times they require a more subtle reshaping or reduction than that seen in men for an improved nasal appearance. Small hump and hook removals can have a big impact on a teenager’s or young woman’s self-image.

But some women have larger noses with thick skin that make them not unlike that of men. Their reductions and nasal reshaping is not subtle and requires more drastic cartilage and bone changes to achieve a more feminine type nose.

Case Study: This 44 year old women wanted to reshape her nose and have it become more proportionate. She hated her large nasal hump and her thick tip which plunged downward. She felt her nose was very masculine and did not match the rest of her face.

Large Nose Female Rhinoplasty result side viewUnder general anesthesia an open rhinoplasty was performed. A large hump eduction was done creating an open roof which required medial and lateral osteotomies to close. The caudal septum was shortened and the tip lifted and narrowed. Her septum was also straightened and her inferior turbinates reduced.

Large Nose Female Rhinoplasty result oblique view Dr Barry Eppley IndianapolisLarge Nose Female Rhinoplasty result front viewWhile she had some immediate improvements in the shape of her nose right when the tapes and splint were removed, it really took a full nine months to see the final shape. The real indicator of when the nose has completely healed and assumed its final shape is when the entire nose (including the tip) feels soft and all the feeling has returned to the skin over the tip. A soft supple tip is the best indicator of the final rhinoplasty.

With the right type of rhinoplasty and even time to heal, even large nose in many women can be given much better shapes that appear more feminine.

Highlights:

1) Rhinoplasty can effectively reduced a prominent dorsal hump and achieve improved tip shape.

2) The controlling factor in many rhinoplasties, including women, is how well the overlying skin can shrink down to the reshaped osteocartilaginous framework.

3) The female rhinoplasty with thicker skin and a larger nose can take many months to achieve its final shape.

Dr. Barry Eppley

Indianapolis, Indiana

August 25th, 2015

Case Study – Upper Eyelid Lifts under Local Anesthesia

 

Background: Upper blepharoplasty surgery, more commonly known as an eyelid lift, is the most common cosmetic eyelid surgery. It is tremendously effective and is associated with a very low risk of complications. While eyelid tissue is very thin and swells significantly after surgical manipulation, the recovery is fairly quick. The results of blepharoplasty surgery is sustained for years although its results are not permanent.

Blepharoplasty surgery is commonly done as part of other aesthetic facial surgeries such as facelifts and browlifts. As a result the swelling and bruising is seen as significant in the context of the overall face and the recovery is comparatively prolonged. But this composite facial rejuvenative surgery belies the otherwise relative ‘simplicity’ of the upper blepharoplasty procedure.

The upper blepharoplasty procedure relies on skin and some orbicularis muscle removal to create its effect. There is a debate as to whether any muscle should be removed along with the skin removal and its effect is primarily believed to help redefine the upper eyelid crease. Proper marking and not excessive tissue removal are the keys to an uncomplicated and satisfactory upper eyelid lift.

Because the upper eyelid is a small structure with thin tissues it can be fairly easily anesthetized by local anesthesia injections. Since the surgery can be done with the surgeon standing above or to the side of the patient and with the upper eyelid closed, the surgery can be performed out of the patient’s field of vision. This further promotes patient comfort.

Case Study: This 42 year old female felt her upper eyes were getting tired and heavy. She felt she had developed some hooding of skin that no amount of eyelid creams or Botox injections around the eyelids could solve.

Upper Blepharoplasty (Eyelid Lifts) under Local Anesthesia Dr Barry Eppley IndianapolisUnder local anesthesia injections into the upper eyelids, a tapering 7mm crescent of skin and muscle was removed along presurgical markings made with a caliper. The tissue segments were removed by scissors which minimized any bleeding. Small dissolveable sutures were used to close.

Upper Blepharoplasty (Eyelid Lifts) under Local Anesthesia oblique view Dr Barry Eppley IndianapolisUpper Blepharoplasty (Eyelid Lifts) under Local Anesthesia side view Dr Barry Eppley IndianapolisWithin one week after surgery she looked essentially no-surgical and had no bruising. Most of her upper eyelid swelling was gone by ten days after surgery. She described the experience as relatively painless and had no discomfort during the procedure and even afterwards.

An isolated upper blepharoplasty can be comfortably and safely performed under local anesthesia in the office. Its effects are immediate and the recovery is very short. Such an office procedure provides the most economic approach to having an upper eyelid lift done.

Highlights:

1) The upper blepharoplasties (eyelid lift) improves upper eyelid shape by removing hooding and redefining the upper eyelid crease.

2) An isolated upper blepharoplasty can be safely and comfortably performed under local anesthesia as an office procedure.

3) An upper blepharoplasty has a quick recovery with only moderate swelling and bruising.

Dr. Barry Eppley

Indianapolis, Indiana

August 23rd, 2015

Case Study – The Extended Tummy Tuck

 

Background: Tummy tuck surgery is one of the most common and successful types of body contouring surgeries. It is used in many post-pregnancy and weight loss women to correct the effects of having babies and the changes that process can induce on one’s body in the mid-section area. This type of tummy tuck usually induce the debate between whether one should have a fully or mini-type of tummy tuck.

But women with a high BMI (body mass index) and significant weight for their height often requires a different type of tummy tuck. Even with weight loss a high BMI creates a roll or rolls of skin and fat that a frontal-based tummy tuck alone can not properly address. The tissue redundancies extend well beyond the frontal hip points and well into the back. This requires that the extent of the tummy tuck excision go around the waistline and become closer to a 270 to 300 degree tummy tuck rather than a traditional 180 degree frontal tummy tuck.

With an extended tummy tuck comes the realization that there will be a longer scar into the back area. This location of a tummy tuck scar often does not look as good as any tummy tuck scar on the abdominal side and there is no real natural skin fold to hide it. For those patients that need it, however, this is usually perceived as an inconsequential trade-off in most cases. It is often also necessary that liposuction be performed in and around the back and waistline area to maximize the contouring effect.

Case Study: This 42 year old female had lost 50 lbs of weight on her own but could not get rid of the rest of her stomach and back rolls. Despite her best effort at exercise she could just not budge her body shape to get any better.

Extended Tummy Tuck results front view Dr Barry Eppley IndianapolisUnder general anesthesia, she had an extended tummy tuck performed with a large horizontal excision of skin and fat from the abdominal area which extended into the back stopping just shy of the midline spine. Her abdominal and flank skin and fat that was removed weight 9 lbs. Liposuction was then performed on her back and lateral chest wall rolls to remove another 1.5 liters of fat aspirate.

Extended Tummy Tuck results oblique view Dr Barry Eppley IndianapolisExtended Tummy Tuck results side view Dr Barry Eppley IndianapolisRecovery time for her extended tummy tuck took a full three weeks to be able to return to any work and a full 8 weeks for a truly complete recovery. Complete recovery is defined as the incision being completely healed with no open areas or sutures that would extrude. And that she was finally back to a full return to all activities including any type of exercise.

An extended tummy tuck is often needed for the patient who has undergone a lot of weight loss or who still carries a fair amount of weight with a high BMI. The resultant scars will be much longer than a standard tummy tuck but is worth the trade-off for a better circumferential waistline reshaping result.

Highlights:

1) Many types of tummy tucks exceed the scope of the traditionally perceived ‘full tummy tuck’.

2) Patients who have lost a lot of weight and started out fairly big before weight loss need an extended type of tummy tuck.

3) Extended tummy tucks create longer scars that wrap around the waistline to lessen the chance of significant skin redundancies and large dog ear deformities.

Dr. Barry Eppley

Indianapolis, Indiana

August 23rd, 2015

Kybella Injections For Submental Fat Reduction

 

Kybella Injections Indianapolis Dr Barry EppleyThe recent approval of Kybella for the treatment of under the chin fat (submental) fat appears like it is a new treatment. And as an FDA-approved drug it is. But the concept of a fat dissolving injectable drug is really now new and has a predicate history in the world of mesotherapy and the now defunct term of Lipodissolve. The active ingredient in many compounding pharmacy (and non-FDA approved) mesotherapy solutions is deoxycholic acid…the same one that is in FDA-approved Kybella.

Kybella is a synthetic version of a naturally occurring bile salt which resides in the gallbladder, known as dexocycholic acid. Known also as deoxycholate and chemically as 3?,12?-dihydroxy-5?-cholan-24-oic acid, it is a secondary bile acid created as a metabolic by product of the intestinal bacteria. The two primary bile acids secreted by the liver are cholic acid and chenodexoycholic acid which bacteria eventually break down eventually into secondary bile acids. Deoxycholic acid is the metabolite from cholic acid.

Kybella Injections Dr Barry Eppley IndianaolisThe role that deoxycholic acid performs in the body is the breakdown (emulsification) of dietary fat so it can be absorbed in the intestine. It has a detergent-like effect on fat to break down the cell walls through solubilization of its  membrane components. It is no surprise then that it is not a far leap to envision how it might work on reducing small subcutaneous fat deposits.Thus the FDA approval after numerous clinical studies for the use of Kybella for a small fat area like that under the chin. (submental fat)

The key to successful use of Kybella is patient selection. It simply is not going to be effective for large fat collections. While patients with larger and fuller necks may be drawn to an injectable therapy for an injectable treatment as opposed to surgery, they will likely be disappointed with the treatment process and the final result. Patients must also understand that this is a series of treatments that works slowly and will take several months to see the final result. It is important to compare this injectable treatment process to what can be achieved just as effectively (and perhaps better0 with a 30 minute surgical liposuction procedure.

Injection treatments take about 15 minutes to complete and are done using a marked grid pattern in the treatment area, spacing them about 1 cm apart. (the solution will diffuse from the injection site about 1 cm in all directions. Based on the treatment area size the number of injections can range from 35 to 50 and takes about 4 ml of the Kybella solution using .1cc volume per injection site. Almost always it takes more than one treatment to see the best result and could be as many as six treatments to see the maximal effect. Injection sessions should be done no closer than four to six weeks to let the maximal fat clearance effect take place.

One immediate and postoperative issue that patients need to be aware of is that significant post-injection inflammation and swelling will occur. Within minutes after the injections the treated area will feel hot and have a burning sensation. Within 48 hours the neck will have a swollen wattle that will go away in one week or less. Some injected areas that will feel numb for a few days. This is the result of how the solution works…an active breakdown and inflammatory process of the treated fat cells. Patients can use NSAIDS and topical ice for pain relief during the first day of treatment. The point is that there is a recovery phase just like surgery. It is not like Botox where they are few noticeable after injection sequelae.

Because there is some important anatomy that runs through the submental area, there are some other associated risks with Kybella injection therapy. This directly refers to the marginal mandibular nerve, the lower branch of the facial nerve that supplies movement to the depressor anguli oris muscle of the lower lip. Such injuries to the nerve have been reported although they all have resolved within several months after the injections. The best way to avoid this disturbing problem is to keep the upper border of the injection level about 1.5 cm below the inferior border of the mandible and to not inject into the jowl areas.

The cost of Kybella injections will vary by physician but a single injection session can run anywhere from $850 to $1,000. Treatment packages of four can run anywhere from $3,500 to $4,000. So patient have to consider carefully the cost of Kybella and treatment times compared to a single surgical submental liposuction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

August 23rd, 2015

Case Study – Custom Occipital Implant in Women

 

Bump it hair accessoriesBackground: One of the most common aesthetic skull deformities occurs in women with concerns about the shape of the back of their head. Lack of adequate fullness at the vertex and upper occipital region creates a flatness that promotes some women to compensate by puffing up their hair to hide it. This is such a common concern that there are even commercial products made to fit under the hair to create that effect. (bump it hair accessories)

Augmentation of the skull in the flat area (occipital augmentation) can correct the aesthetic skull deformity. This can be using a variety of materials and the decisions are about what material and the incision needed to place it. Historically bone cements (e.g., PMMA) were the common method of occipital augmentation placed through a fairly long scalp incision. A more contemporary method is the fabrication of a custom implant made of silicone material that is designed from the patient’s 3D CT scan.

The use of a custom occipital implant requires a design that can adequately correct the skull deformity but not be too big that the overlying scalp can not accommodate it. There is no exact science as to how much occipital skull augmentation any patient can take but my experience indicates that 12mm to 15mm at the height of augmentation would be the maximum. This would require a longer scalp incision to be placed. If done through more distant and limited incisions the maximum thickness of the implant should be closer to 10mm to 12mms.

Custom Occipital Implant Design Dr Barry Eppley IndianapolisCase Study: This 30 year old female desired to have greater occipital fullness to create the ‘bump it’ effect. She was tired of having to fluff up her hair to create that fullness and sought a permanent solution through skull augmentation. She opted for a custom implant design that was done using a 3D CT scan of her skull.

Custom Occipital Implant Dr Barry Eppley IndianapolisCustom Occipital Implant in Female result side view Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, a low occipital incision was made at the bottom of her hairline. A wide subperiosteal pocket was made up over the back of the occiput to the vertex. The custom occipital implant was perforated with multiple 3mm perfusion holes and inserted. It was positioned as high up on the occiput as possible. A single 1.5mm titanium screw was used to secure its midline position. The scalp was closed in multiple layers with dissolveable sutures.

The custom occipital implant is a very effective method for creating a permanent internal ‘bump it’ effect. The custom design must balance the thickness and dimensions of the implant versus how much the scalp can stretch to accommodate it. There is also the issue of the location and length of the incision to place it. If the implant is not too big it can be placed with relative ease through a low hairline occipital incision.

Highlights:

1) Inadequate fullness or flatness of the back of the head is a common aesthetic skull concern amongst women.

2) Occipital augmentation can create the ‘bump it’ effect that some women want to create more fullness at the top of the occipital bone. (vertex)

3) A custom occipital implant is the most effective method for creating increased skull fullness at the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

August 22nd, 2015

Case Study – Platelet Rich Plasma and Hydroxyapatite Granule Maxillary Defect Reconstruction

 

Background: The nasopalatine cyst is a well known pathology of the maxilla that often presents as an asymptomatic anterior palatal swelling. It usually develops behind the maxillary incisors and is thought to be caused by the ductal tissue within the incisive canals. It appears radiographically as a round or heart-shaped mass in occlusal plane or 2D CT x-rays or as a very distinct round tumor in 3D CT facial scans. While benign it can cause significant bony erosion through its expansile growth.  By the time it appears as an anterior palatal swelling the amount of bony destruction is significant.

Treatment of the nasopalatine cyst is done through excision by raising a posteriorly based soft tissue flap. When removing the cyst lining from the palatine bony defect it is important to get all of the cystic lining up into the nasopalatine ducts to prevent recurrence. When the resultant bony defect is small no reconstruction is needed. But by the time a nasopalatine cyst is discovered the bony defect is large and ensuring bony fill is often needed to provide hard tissue support to the maxillary incisor teeth. While an autologous bone graft is ideal patients understandably would like to avoid a graft harvest.

Demineralized bone substitutes as well as hydroxyapatite synthetic grafts are appealing in the facial bony defect that has good vascularity and numerous walls to contain it. This may be enough for some patients but agents that can accelerate or magnify the bony response are appealing. One such healing is that of platelet-rich plasma.

Platelet-rich plasma (PRP) has been used in a wide variety of bony and soft tissue applications to expedite healing and tissue repair. As an extract of a patient’s blood, the platelet concentrate is known to contain powerful growth factors which are important participants in the wound healing process. PRP undoubtably has its greatest effect when it is combined with other natural tissue grafts such as bone and fat grafts. But it can also be useful with allogeneic and synthetic type grafts which have no cellular component and rely heavily on the body providing the proper healing milieu.

Nasopalatine Cyst x-ray Dr Barry Eppley IndianapolisCase Study: This 26 year-old female presented with a painless swelling of her anterior palate. It measured 3 x 3 cms. She had a prior history of dental trauma as a teenager that resulted in endodontic treatment (root canals) of her anterior incisor teeth. An occlusal radiograph showed an irregular radiolucent mass of the anterior palate. She did not want a bone graft harvested should it be needed.

PRP and HA granules mixture for nasopalatine defect reconstruction dr barry eppley indianapolisNasopalatine Defect Reconstruction with Platelet Rich Plasma and Hydroxyapatite Granules Dr Barry Eppley IndianapolisUnder general anesthesia the anterior palate was exposed by raising a soft tissue flap. The cystic mass and its lining were removed down to the apices of the roots of the teeth. This left a bony defect that partially exposed the palatal surfaces of the tooth roots. Reconstruction of the bony defect was done by a combination of hydroxyapatite granules and PRP. She went on to a completely healed wound with teeth retention and stability.

Hydroxyapatite granules is one of the oldest synthetic bone grafts that can still be successful to its inorganic calcium phosphate similarity to natural bone. When mixed with PRP the surrounding bony ingrowth into the material is accelerated ensuring a rapid and complete bony fill of the defect.

Conclusions:

  1. Nasopalatine cysts can develop from periapical abscesses/non-viable tissue from teeth that had previously undergone root canals.
  2. Excision of the complete nasopalatine cyst is necessary for a long-term cure without recurrence.
  3. PRP mixed with synthetic bone grafts can be successful reconstruction strategy for larger maxillary bony defects.

Dr. Barry Eppley

Indianapolis, Indiana

August 21st, 2015

Case Study: Bilateral Cleft Lip Repair

 

Background: Cleft lip and palate is one of the most common facial birth defects often cited as occurring in about 1 in every 1,000 births. While there are race, gender and world wide differences in this occurrence rate, it is a condition that is well recognized around the world for its prevalance. Almost everyone has seen or knows someone who has been affected by some facial cleft problem.

Despite the generic name of cleft lip and palate, it  is a collection of orofacial birth defects that has a wide range of variability in how it appears. The cleft can affect one side of the lip, both sides or can cause a cleft palate only. Even in bilateral cleft lip and palate there is great variability. The cleft lip may be complete on both sides, complete on one and incomplete on the other, or incomplete on both sides. This variability in the cleft ip becomes compounded when one factors in the internal cleft palate and alveolar component which can occur variably as well.

Regardless of the type of bilateral cleft lip and palate deformity, the first step in the reconstructive process begins with the bilateral cleft lip repair. While usually done at around 3 to 4 months of age, its timing may be affected by the location of the premaxillary segment beneath the cleft upper lip segment. If it is excessively protrusive and displacing the central upper lip segment far forward, its repositioning by tapes or active appliances (e.g., nasoalveolar molding) may be needed first. Such manuevers put the central lip segment closer to the sides of the lip to avoid extreme tension on the bilateral cleft lip repair after surgery.

Case Study: This infant male was born with a bilateral complete cleft lip and palate deformity. Despite being complete the central lip segment was not projecting too far forward because of the good position of the underlying premaxilla. Taping of the lip segments was done which was adequate for central and lateral lip alignment. Under general anesthesia at 4 1/2 months of age a bilateral cleft lip repair was performed.

Bilateral Cleft Lip Repair submental view Dr Barry Eppley IndianapolisBilateral Cleft Lip Repair oblique view Dr Barry Eppley IndianapolisHis postoperative results showed that a fairly good initial result with all of the main objectives of a bilateral cleft lip repair achieved. This was helped considerably by the extent of the bilateral cleft deformity and the not unduly protrusive position of the underlying premaxilla. Not all bilateral cleft lip repairs will end up with such good lip repair results. Such a favorable initial lip repair sets the stage for promising additional reconstructive surgery results.

Bilateral Cleft Lip Repair result front view Dr Barry Eppley IndianapoliisBilateral cleft lip repair is challenging. Multiple objectives are strived for including keeping the width of the central lip segment narrow, reconstruction of a cupid’s bow and central vermilion (pink part of the lip), and have a symmetric height of the both sides of the lip without extending the incision around the base of the nose to name a few of the most important.

Highlights:

1) Bilateral cleft lip and palate is the most severe form of the typical facial cleft birth defects.

2) Reconstruction of the bilateral cleft lip and palate deformity consists of a number of orofacial procedures (often 6 to 8 total) done up to 18 years of age.

3) The first reconstructive surgery in the bilateral cleft patient begins at 4 months of age with an initial bilateral cleft lip repair.

Dr. Barry Eppley

Indianapolis, Indiana

August 17th, 2015

Cupid’s Bow Lift of the Upper Lip

 

Augmentation of the upper lip is one of the most commonly done non-surgical facial enhancement procedures. This can usually be successfully done through the use of a variety of different hyaluronic acid-based injectable fillers. Despite their popularity and frequency of use, however, injectable fillers can not solve all aesthetic upper lip concerns. A thin upper lip with little vermilion height often does not respond well to volume addition alone and is prone to result in the dreaded ‘duck lip’ look where most of the filler volume comes horizontally forward rather than increasing vertical vermilion height.

Surgical lip augmentation offers a better result in the thin upper lip because it can alter the location of the vermilion-cutaneous junction…the one anatomic feature by which lip size and shape is mainly judged. This can be done by an ‘upper’ lip procedure known as a subnasal lip lift or a ‘lower’ upper lip procedure known as a vermilion advancement. While very close by location the effects of these two surgical lip procedures can be dramatically different.

One way that they differ is in the effects on the cupid’s bow area. An aesthetically important feature of the upper lip, the cupid’s bow or tubercle, is a double curve of the lip which resembles a bow laid on its side. The peaks of the bow coincide with the vertical philtral columns coming down from the nose giving a prominent bow appearance to the upper lip. While a subnasal lip lift will pull up on the central cupid’s bow area it will really reshape or ‘sharpen up‘ its shape. Only a vermilion advancement can create that change since it changes it directly by skin excision.

Cupid's Bow Augmentation Surgery Technique Dr Barry Eppley IndianapolisCupid's Bow Upper Lip Augmentation Surgery Dr Barry Eppley IndianapolisA cupid’s bow lift can be created as an isolated procedure (in an upper lip with adequate volume) or can be combined with other lip enhancement procedures such as injectable fillers or a subnasal lip lift. Removing a few millimeters of skin can really change the cupid’s bow appearance even if it is just limited to the peaks of the cupid’s bow alone.

While cupid’s bow augmentation does create a fine line scar at the new vermilion-cutaneous junction it typically heals very well as it is not under undue tension due to the limited resection area.

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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