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.

March 7th, 2015

Subfascial vs. Intramuscular Buttock Implants


voluptuous back in pink pantiesThe use of implants is one effective method for buttock augmentation. It is far surpassed by fat injections (aka Brazilian Butt Lift, BBL) in number of buttock enhancements done, however, due to the appeal and usual availability of adequate fat to harvest to do the procedure. The exact numbers are not known but I would estimate that for every 25 to 50 BBL surgeries done in the U.S.,  only several buttock implant procedures are done. It is probably a 10:1 ratio of BBL to implant surgeries.

But the tremendous rise of BBL surgeries has also led to an increase in buttock implant surgeries. This is because some people are not good candidates for fat injections because they do not have an adequate donor source of material. There may also be some ‘failures’ in BBL surgeries due to fat absorption and minimal augmentation outcomes as a result.

Buttock Implants Augmentation Dr Barry Eppley IndianapolisButtock implants is the most reliable method of buttock enhancement because the implant’s volume is stable and does not change after surgery. Unlike BBL surgery, implants can achieve only a certain amount of augmentation due to the limits of implant sizes made and the tissue pockets that can be created to contain them.

Like breast implants, there are two locations in which the buttock implants can be placed. Buttock implants can be placed either intramuscular (not beneath but inside the gluteus maximus muscle) or subfascial. (above the gluteus maximus muscle) There are advantages and disadvantages to either implant location. Neither implant location is necessarily better than the other and each patient must be considered individually based on their buttock shape, tissue thickness and their buttock enhancement goals.

Subfascial Buttock Implants Dr Barry Eppley IndianapolisSubfascial Buttock Implants Indianapolis Dr Barry EppleyHistorically subfascial buttock implant placement has been most commonly done. It is somewhat simpler to technically perform, has a less painful recovery, and enables the largest buttock implant sizes to be placed. Since the implant is more superficial with less tissue coverage, it is best to place in patients that have some subcutaneous fat tissue thickness. Its disadvantages are that it has a higher rate of infection and seromas and the outline of the implants could be more visible. If intergluteal wound dehiscence occursm the implants are at greater risk of infection. It also has a higher long-term risk of tissue thinning and greater implant profile visibility.

Intramuscular buttock implants is becoming a more common surgical technique but it is still done far less than subfascial buttock implants. It has the advantages of providing good vascularized tissue coverage of the implants and has a lower risk of infection and seroma formation as a result. Because the implants are placed deep, one can still have fat injections done above them for further augmentation later if desired. Its disadvantages are that it is a more ‘complex’ surgical technique to master and its is more painful with a more difficult recovery in the first few weeks after surgery. Its most limiting aspect is that the intramuscular space offers only a limited capacity to handle implant size with the upper limits in the 300cc to 350cc range.

Buttock implants will never rival fat injections but they have a significamt role to play in buttock augmentation. They remain as the only option for those patients that have inadequate fat stores for the BBL procedure.

Dr. Barry Eppley

Indianapolis, Indiana

March 5th, 2015

Case Study – Lateral Canthopexies for Changing The Corner Of The Eye


Background: The shape of the eye has a significant impact on both facial appearance and expression. Its inner and outer shape is largely created by the overlying eyelids and how they come together and attach to the inside and outside of the orbital bones. The union of the upper and lower eyelids forms the inner and outer corners and this union also creates the aperture or angle between eye corners. The outside corner of the eye is probably the more important half since it controls the horizontal orientation of how eye shape is perceived.

Eye Shape Dr Barry Eppley IndianapolisEye shape most commonly has a neutral axis or a completely horizontal orientation. This means that the inner and outer eye corners are at the same horizontal spot on the orbital rim bones which creates a straight line across the eye when drawn between the two. A downward eye tilt means that the outer corner is lower than the inner corner. Conversely, an upward tilt to eye shape means that the outer corner is higher than the inner.

A horizontal or upward tilt to the outer corner of the eye is seen as most desired. Some women even prefer a more exaggerated or exotic eye cant with the outer corner being much higher than the inner corner. A downward eye tilt, which some people have naturally, is seen as undesired and can also occur from loss of outer corner lid support from any type of lower eyelid surgery.

Case Study: This 22 year-old female wanted to change the outer corner of her eyes slightly to fix their asymmetry and eliminate excessive scleral show. This was her natural eye shape and eyelid position.

Lateral Canthopexy results Dr Barry Eppley IndianapolisBecause she was having numerous other cosmetic procedures, her surgery was done under general anesthesia. Through a 7mm skin incision in the outer skin crease, lateral canthopexies were performed. The outer corners of the eye were sutured up higher on the outer aspect of the lateral orbital rims with small permanent sutures. The skin incisions were closed with very small resorbable sutures. Her six month after surgery pictures show the sustained improvement in her lower eyelid outer corner repositioning.

Lateral Canthiopexy result oblique view Dr Barry Eppley IndianapolisLateral Canthopexy results side view Dr Barry Eppley IndianapolisLateral canthopexies can elevate the outer corner of the eye and can do so without creating a bowstring or tightening effect across the entire lower eyelid. Because it stays on the outside of the bone (rather than inside like a lateral canthoplasty) it does not shorten the horizontal length of the lower eyelid. In addition, it helps to correct prevent rounding of eye shape which is more associated with that of an aging look.

Case Highlights:

1) Improving the upward tilt  of the corners of the eyes can be done by either lateral canthopexy or lateral canthoplasty techniques.

2) Lateral canthopexy vs. canthoplasty have different impacts of eye shape.

3) A lateral canthopexy technique is less likely to round out the eye shape and shorten the horizontal length of the lower eyelid.

Dr. Barry Eppley

Indianapolis, Indiana

March 5th, 2015

Five Things You Didn’t Know About Custom Skull Implants


Unlike facial implants, the use of skull implants for aesthetic head reshaping has a very short history. While the use of facial implants dates back more than five decades in plastic surgery, skull implants have been done for just a few years. It has not been that skull implants are radically different or more complex to perform, it is just that there are no preformed skull implants currently available. With facial implants, there are dozens of different preformed options for the nose, cheek, orbital rim, chin and jaw angle areas.

custom occipital implant design side view jmUntil preformed standard size skull implants become available for certain head shape concerns, they will have to be custom made custom for each patient based on their specific anatomy from a 3D CT scan. As custom skull implants are becoming more used due to improved manufacturing technology, there is still little public awareness about them. Here are some things you may not know about custom made and manufactured skull implants.

Custom Skull Implants Have Made Cosmetic Head Reshaping Possible.  What really separates skull from facial implants from an implant standpoint is their size. Covering broad areas of the skull (e.g., back of the head) creates an implant that would be equivalent to over 20 or more chin implants. Getting such an implant to fit well is much more difficult than smaller facial implants and the margin of error is actually much less because of its size. The custom design and manufacturing of a skull implant makes their use much more predictable for any skull area.

A 3D CT Scan Is Needed To Make Custom Skull Implants. Whether it is done by an actual model or on the computer screen, only a high resolution 3D CT scan of the skull can be used. The scan has to be done using .1mm slices and not the standard 3mm or 1mm slices normally taken. A regular axial or coronal head CT scan will not work nor will an MRI. Today 3D CT scanning is widely available, quick and easy to do acan be done for a few hundred dollars.

The Computer Only Designs What The Surgeon Tells It To Do. While computers and their software have remarkable capabilities, they do not yet know how to create a specific look for any patient. In designing skull implants, it is important to remember that the computer has no innate knowledge of what the size and shape the implant needs to be for what the patient wants to be. The surgeon must work with the design engineer to create the amount of skull surface area (shape) and thicknesses of the implant to create what is believed to cause the ultimate aesthetic outcome. The computer design process will make sure the implants fit the bone perfectly, compensate for any skull asymmetries, have a smooth outer surface and will minimize any edge transitions.

Skull Cap Imnplant Design Dr Barry Eppley IndianapolisThe Limiting Factor In Skull Implants Is The Overlying Scalp. Unlike facial implants, skull implants must carefully consider the tolerance of the overlying scalp tissue to stretch and accommodate it. Facial implants rarely have his consideration because they are smaller and the facial tissues have greater elasticity. The size of skull implants and the tightness of the scalp stretched over a large convex bony surface makes its design of critical consideration. Knowing how large and thick a skull implant can be is a matter of the surgeon’s experience. When the need for large skull implants exist, a first-stage scalp expansion may need to be considered.

Incisional Access Is Of Critical Importance In Custom Skull Implants. With large implants, the need to preserve hair follicles and to not create an additional aesthetic problem (scalp scar), the location and length of scalp incisions is critical. Despite most skull implant sizes they can be placed through relatively small incision in many cases because they are flexible. The implants can also be sectioned into two pieces and ‘reassembled’ once inserted if need be.

Dr. Barry Eppley

Indianapolis, Indiana

March 4th, 2015

Technical Strategies – Direct Fixation Method for High Tail Browlifts


Numerous browlift procedures exist to lift sagging brows and help rejuvenate an aging periorbital look. The success of most browlifts are based on a tissue release and a superior elevation of the sagging brows. Most techniques employ some form of fixation to the skull bone to hold the lifted forehead tissues as they heal. These have included a variety of metal and resorbable polymer devices that have taken the forms of pins, screws and platform style plates. They don’t have to hold the tissues very long as it has been shown that periosteal healing back to the bone in the new position takes about two weeks or less.

Male vs Female Eyebrow ShapeHow much to elevate sagging brows and how to shape them as they are lifted is as much an art form as it is a science. How the brow arch gets shaped as it is lifted is affected by numerous factors such as incision and tissue fixation location as well as the amount of upward pull. What is known is that the shape of the shape of the brows and the amount they can be aesthetically lifted does differ significantly between women and men. Women can tolerate higher amounts of browlifting with an arch shape that is often preferred to be higher at the outer aspect than the inner brow area. Conversely, men can tolerate only a modest amount of browlifting and the arch shape should stay relatively flat. (unarched)

A few women do prefer a  more dramatic browlift result which usually refers to a very high tail of the brow. This is often accompanied with a high outer corner of the eye lift as well. Such high tail of the brow positions can be difficult to achieve as they require a significant upward tissue lift and are almost always done best through a pretrichial or hairline incision to avoid backward displacement of the frontal hairline.

Direct Tail of the Brow Pexy technique Dr Barry Eppley IndianapolisDirect Tail of the Brow Pexy technique 2 Dr Barry Eppley IndianapolisOne simple method of brow fixation that I have found useful in these more extreme browlift procedutes is a direct browpexy method. Once the maximum amount of lift of the tail of the brow is achieved, a 3mm stab incision is made inside the hairline of the outer brow. Using a self-tapping 1.5mm screw, the deeper brow tissue are grasped lifted and secured to the underlying bone. The screw can be used to either hold the existing brow position or to even lift it up higher before placing the screw into the bone. If the tail of the brow is lifted up even higher, a skin bunching around the tail will occur. Thus will need to be released right under the skin with small sharp scissors. It is important to make sure the screw is turned down flush to the bone since it is not paplpable. A small resorbable sutures is then placed to close the tiny incision.

Tail of the Brow Lift intraop result Dr Barry Eppley IndianapolisThis direct brow fixation method is a useful adjunct to securing the outer tail of the brow in select cases. A direct browpexy may be necessary when a very high arch shape is desired amongst female patients.

Dr. Barry Eppley

Indianapolis, Indiana

March 2nd, 2015

Vertical Excision Technique for Chin Ptosis Correction


The number of different procedures available for correction of chin ptosis (chin pad ptosis) indicates that there is no one single procedure that works the best. While chin ptosis correction techniques vary, it is important to appreciate that there are different anatomic variants of chin ptosis. There are contributions of bone, skin and fat, mentalis muscle and lower lip positioning. Together these create different types of chin ptosis problems.

vertical wedge excision for chin ptosis correction 1vertical wedge excision for chin ptosis correction 2In Volume 3 Number 2 2012 issue of Plastic Surgery Pulse News, an article appeared entitled ‘A Novel Correction of Chin Ptosis By Vertical Wedge Excision of Subcutaneous Soft Tissue’. Using a single patient example, the authors describe a vertical midline wedge excision of soft tissue. In this technique the vertical laxity of the ptotic chin pad is tightening along the inferior border of the chin mental border while correcting the horizontal tissue laxity as well. The technique also improves anterior chin projection and softens the labiomental crease as well. This vertical wedge of mentalis and soft tissue when brought together creates a clothesline effect that helps reposition and suspend the ptotic tissues up over the lower anterior border of the mandibular symphysis. In the process, the soft tissues of the chin pad are rotated upward, augmenting the anterior chin and re-creating the labiomental fold. Any excess skin and subcutaneous fat is then trimmed in a horizontal fashion in the submental region.

Muscle Resuspension in Submental Chin Ptosis Correction Dr Barry Eppley IndianapolisThis vertical wedge excision technique for chin ptosis correction is based on tissue excision rather than tissue resuspension. That is a fundamental difference and requires an appreciation of whether the patient’s chin ptosis has a component of excessive chin tissues or not. By using a vertical excision of chin pad tissues, a vertical triangular excision creates a clothesline effect that allows the remaining chin pad to be positioned superiorly and anteriorly. It is easy to see why this technique could cause an abnormal bunching of chin tissues if the chin ptosis was caused by laxity and not excessive tissue as well. The authors acknowledge that this technique is not useful for every chin ptosis problem, particularly when there is already too much chin projection present.

Chin ptosis is a multifactoral problem that has different anatomic variants. The first important classification is whether the chin ptosis is associated with a lower lip sag or not. If there is no lower lip sag there is no benefit to mentalis muscle resuspension or trying to move the chin tissues back upon the one. The next important chin ptosis classification is whether there is excessive chin tissues or whether there is a normal amount of tissue volume. If the overhanging chin tissues are normal in volume, and their resection may be associated with causing a lower lip sag, then resuspension should be done. When the ptosis is caused by excessive chin tissues then resection would be the appropriate approach.

When it comes to resection of the chin pad, it can be done horizontally (under the chin), vertically (as shown in the article) or through a combined vertical and horizontal technique. (inverted T) There is no question that adding a vertical direction to the chin pad excision provides an additional element of chin pad reduction that is helpful.

Dr. Barry Eppley

Indianapolis, Indiana


March 2nd, 2015

Case Study – Lip Advancement Revisions


Background: Lip augmentations are very popular and are most commonly done with the use of injectable fillers. But not every smaller lip can be satisfactorily augmented by fillers alone and, even when a satisfactory result is achieved, women may eventually tire of the need for repeated injection sessions and their cost.

Lip Advancement Dr Barry Eppley IndianapolisA lip advancement is one of the three surgical lip augmentation options which include lip lifts, lip advancements and lip implants. The lip or vermilion advancement procedure is the most effective lip augmentation procedure because it does what ultimately makes lips permanently bigger…it changes the vermilion or pink part of the lip to have more vertical exposure. And it does so from one mouth corner to the other which is what differentiates it from the lip lift which only changes the central part of the upper lift. The lip advancement can be done equally well on the lower lip as well as the upper lip.

The one disadvantage to the lip advancement is that it creates its powerful effect at the expense of a fine line scar at the vermilion-cutaneous border. These lip advancement scars can be very minute and acceptable in most cases. But there is very little tolerance for even the smallest asymmetries in the shape of the lip particularly in the cupid’s bow area.

Lip Advancement Asymmetries Dr Barry Eppley IndianapolisCase Study: This 40 year-old female has a prior upper and lower lip advancement  from another surgeon that turned out to have significant lip asymmetries. The cupid’s bow was oriented to the left of the midline and the height of the lower lip vermilion was very different between the two sides. This gave the lips a very unnatural and twisted appearance.

1st Stage Lip Advancement Revision Dr Barry Eppley IndianapolisUnder local anesthesia in the office, new lip vermilion edges were marked to realign the lips shape. New skin areas were cut out and the vermilion edges realigned. Her postoperative result showed substantial improvement but healed with some minor scar hypertrophy at the peak of the left cupid’s bow and along the outer thirds of the right lower lip.

2nd stage lip advancement revision Dr Barry Eppley IndianapolisA second stage lip revision was done under local anesthesia six months later. The left cupid’s bow was repositioned and the right lower lip hypertrophic scar excised.

Lip Advancement Revisions front view Dr Barry Eppley IndianapolisLip Advancement Revisions Indianapolis Dr Barry EppleyAfter two revisions, a satisfactory lip advancement revision result was obtained.

While the concept of lip advancements is simple, its execution requires careful preoperative markings, precise skin cutouts and a meticulous closure. The very visible presence of the lips on the face make any amount of asymmetry or hypertrophic scarring very apparent. Revisions of lip advancement problems usually led to a much improved and more symmetric outcome.

Case Highlights:

1) Lip advancements are technically precise procedures that must be measured before surgery and technically executed carefully.

2) Revisional surgery can salvage asymmetric lip advancement results.

3) It may take more than one revision to optimize lip shape and scar outcomes from adverse lip advancement problems.

Dr. Barry Eppley

Indianapolis, Indiana

March 1st, 2015

Zygomatic Arch Fractures and Their Repair


NBA player cheekbone fractureFacial fractures are common injuries and sporting activities are a common source of them. This was well illustrated by a well chronicled facial injury sustained recently in the NBA. Oklahoma City’s Russell Westbrook was injured in a game last Friday in Portland when his teammate’s knee collided into the right side of his face in the last minute of the game. This left an immediate imprint in the side of his face between the eye and the ear. The next day he had surgery to repair a ‘cheekbone’ fracture.

Understanding the anatomy of the cheek bone, technically known as the zygomatico-orbital complex, will explain the specific type of facial fracture this NBA player sustained. The distinct imprint on the side of his face was caused by a zygomatic arch fracture. This is the very thin stick of bone that goes from the main body of the cheekbone (zygoma) back to its attachment to the temporal bone in front of the ear. It is like an arched bridge that spans the cheek and skull to let the large temporal muscle go underneath it.

zygomatic arch fracture Dr Barry Eppley Indianapoliscomminuted zygomatic arch fracture dr barry eppley indianapolisBecause the zygomatic arch is so thin, it is one of the most easily fractured bones on the face. But it requires a direct blow to the height of the arch to create a displaced fracture. It usually fractures inward like a V with two collapsing spans of a bridge. But it can also be a comminuted type zygomatic arch fracture where it breaks into multiple pieces and the entire ‘span of the bridge’ falls inward.

Zygomatic Arch Fracture Repair Dr Barry Eppley IndianapolisRepair of a displaced zygomatic arch fracture is unlike just about every other facial fracture other than that of the nasal bones. It is located in an area where direct surgical access is impossible due to branches of the facial nerve. Without direct access it is not possible to rigidly fix the fracture with plates and screws. (at least not very easily) Thus zygomatic arch fractures are repaired from a remote incision in the temporal scalp and are elecated back up into position off of the temporalis muscle.

Zygomatic arch fracture repairs are, by definition, unstable since they are not rigidly fixed back into place. This is why you will usually see some type of protective device over the side of the face to prevent secondary inward displacement while it heals.

Dr. Barry Eppley

Indianapolis, Indiana

February 28th, 2015

Case Study – Anatomic Implants for Natural Breast Augmentation


Background: As a device driven operation. breast augmentation has a variety of implants styles, shapes and sizes from which to choose. Understandably prospective patients think the implant chosen will result in the way the breast will look after surgery. While there is no doubt the implant has a major influence on the result, the natural features of the breasts make a contribution as well.

Shaped Anatomic Breast Implants Dr Barry Eppley Indianapolis copyThe introduction a few years of the anatomic or shaped breast implant has caught many patient’s attention. Often touted as creating a ‘natural’ breast augmentation result, the implant’s tear drop shape offers something different than the traditional round implant. Being only available as a silicone filled implant, its other noteworthy feature is that it has a textured non-smooth surface.

When looking at the anatomic breast implant it is important for the patient to understand what it’s advantages and disadvantages are. The primary purpose of the tear drop shape is to maximally ensure that the final breast augmentation result will not be too round or ‘unnatural’.  An unnatural breast augmentation result for some women is defined as an augmented breast that is as full on the upper half as it is full on the lower half. While some women prefer that result, many do not. Because the anatomic implant has its distinct shape, it is important that it does not move around or the breast will become deformed. Hence the purpose of the textured surface so the tissues adhere quickly to it and it becomes positionally stable of fixed into position.

Despite the benefits of the shaped implant, it has several relatively minor disadvantages. The textured surface make the implant’s shell twice as thick leading to a bit of a stiffer feeling implant. Because of tissue adherence to the textured surface, the breasts will not move much unlike natural breasts. Because the implant’s positioning is critical to the postoperative shape of the breast, its surgical placement is best done through an inframammary fold incision. Lastly, the cost of anatomic shaped breast implants will be higher than round smooth silicone breast implants.

Case Study: This 35 year-old female wanted larger breasts but was concerned they may look unnatural. She wanted a more natural looking augmentation that did not turn out like a big round breast shape. She specifically wanted shaped or ‘tear drop’ implants to address her breast shape concerns.

Jennifer Breast Augmentation results front viewJennifer Breast Augmentation results oblique viewUnder general anesthesia, textured anatomic shaped breast implants of 400cc size (Sientra) were placed through 4.5 cm inframammary incisions using a funnel insertion technique.

Jennifer Breast Augmentation results side viewEven at one week after surgery, she did not have the typical highly positioned breast implant look. At six weeks after surgery she had a much fuller size but a natural shape to her breasts. With her smaller initial breasts with fairly tight skin such a breast shape would not have been possible with traditional smooth round silicone implants.

Case Highlights:

1) Natural breast augmentation is both a function of implant size and shape.

2) An upper breast pole that is less full than the lower pole is the main description of a naturally looking breast augmentation.

3) Textured shaped implants are the best breast devices to help achieve the most natural look in breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

February 27th, 2015

Lateral Canthopexy vs Canthoplasty – Implications for Eye Shape


Changing the outer corner of the eye is done for a lot of different aesthetic and reconstructive purposes. The two main reasons are to help correct a lower lid sag from prior surgery (reconstructive) or to create more of an uplifted corner of the eye to change its appearance. (aesthetic) The procedures used to do so are either a lateral canthopexy or a lateral canthoplasty

Lateral Canthopexy Dr Barry Eppley IndianapolisThe changes that occur between a canthopexy and canthoplasty is often subtle but how they are performed, their indications and the effects that result from their use is very specifically different. Understanding these eye corner manipulations requires an appreciation of eye shape.

The shape of the eye is really determined by how the upper and lower eyelids join at the corner.  This is much more so at the outer corner of the eye than the inner. (at least for Caucasians) A youthful eye is associated with a space between the upper and lower eyelids that is narrow and more drawn out to the side. In some ways it is a tight ‘bowstring’ look provided that the bony anatomy of orbit and cheek is normally developed around it. As one ages the shape of the eye changes as the lower eyelid droops. This creates an eye shape that is now rounder and horizontally shorter. In effect the bowstring effect is weakened.

Lower Blepharoplasty without lateral Canthopexy Dr Barry Eppley IndianapolisThe very frequently performed aesthetic lower blepharoplasty procedure has a high incidence of changing the outer corner of the eye. Careful inspection of many before and after surgery pictures of lower blepharoplasties will show some dropping of the lid margin, even some increased scleral show and an eye that appears slightly rounder. The changes that lie below it can show dramatic improvement with elimination of protruding fat and loose skin but the trade-off in some patients can be a slightly rounder eye and lower lid margin. This phenomenon is well recognized and accounts for today’s trending towards more tissue preservation of the lower lid and the addition of orbicularis muscle suspension support at closing.

Lower Blepharoplasty with lateral Canthopexy Dr Barry Eppley IndianapolisThe role of lateral canthopexy is greatest in lower blepharoplasty surgery for prevention of eye shape change or to restore a rounded corner afterwards. In a cnanthopexy, the point of union of where the upper and lower eyelid meet is changed and fixed to the outer aspect of the lateral orbital rim. in essence the corner is ‘pexed’ outward creating a longer and more narrowed eye shape. This is done with small sutures to the periosteum on the bone.

Conversely, a lateral canthoplasty is more invasive and requires fixing deeper tissues of the lower eyelid (tarsus or muscle) to the inner aspect of the lateral orbital rim. This is usually most effectively done by placing drill holes in the lateral orbital rim where a transosseous suture can be passed to ensure that the new canthal attachment is ‘high and tight’ inside the orbital rim.

While effectively restoring the bowstring effect of the lower eyelid against the eyeball, it does so at the expense of shortening the lower eyelid and giving it a rounder shape. For this reason lateral canthoplasties are primarily used as a reconstructive procedure for significant lower lild retraction. It restores lower lid competence but not necessarily a more youthful looking eye shape.

Dr. Barry Eppley

Indianapolis, Indiana

February 27th, 2015

Case Study – Flat Back of the Head Correction with Custom Occipital Implant


Flat back of head Dr Barry Eppley IndianapolisBackground: The most common aesthetic skull deformity is that of the flat back of the head. This occurs most commonly from in utero or postnatal infant positioning and also has a strong genetic tendency amongst certain ethnic groups. (e.g., Asian)  While a flat back of the head has no detrimental intracranial or neurologic effects, it can be very psychologically bothersome to some people. To those so affected, it causes a variety of efforts at hairstyle and hat management to camouflage the shape of the skull.

A variety of augmentation procedures have been done over the years for the flat back of the head deformity. It is merely a question of what materials have been used, how they are shaped and what type of incisional access is needed to do so. Injectable materials like synthetic fillers and fat, while appealing, simply do not work. The scalp is not like the face, breasts or buttocks. It is much stiffer and has no real fatty layer into which filler materials be easily placed. While some injected fat may survive, it runs a high risk of being irregular and can never create much overall volume augmentation.

Bone cements have been the most popular skull augmentation materials. While they can be effective they require fairly long scalp incisions to properly place and shape them. When placing them through smaller incisions they run the risk of palpable irregularities and edge transitions. The kocation of the incision is often needed right near or over the cement application which potentially poses a healing issue when the scalp closure is very tight.

In my practice, bone cements have largely given way to custom skull implants made from the patient’s 3D CT scan. This method offers significant advantages including a precise shape and thickness augmentation, a much lower risk of edge transition and irregularities, shorter operative times and a scalp incision that is located away from the implant’s maximal tension of the overlying scalp

Case Study: This 30 year-old female had long been bothered by the flatness at the top of her head. She styled her hair to puff it up in the back to add volume to the back of her head. She finally wanted a more definitive and permanent solution. She did have a very pertinent prior cosmetic surgery history having had a strip graft harvest from the back of her head for hair transplantation to lower her frontal hairline.

Custom Occipital Implant design Dr Barry Eppley IndianapolisCustom Occipital Implant design 2 Dr Barry Eppley IndianapolisA 3D CT scan was used to design a silicone occipital implant to cover the back of her head. Its maximal thickness was 12mm in the central projection area. Because of her prior hair transplant, she had lost at least 1 cm of scalp flexibility. The thickness of the implant was kept to 12mm to ensure that it would fit without undue tension on the scalp incision and also not to compromise the blood flow to the central scalp over the implant.

Cusytom Occipital Implant Dr Barry Eppley IndianapolisIncision for Custom Occipital Implant Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, her prior hair transplant scar was used for access. At the tail end of the incisions the occipital neurovascular bundles were identified and preserved. Long curved instruments were used to develop a subperiosteal pocket around the curved contours of the back of the skull. The custom implant was prepared by placing multiple perfusion holes using a 2mm punch. It was fairly easily inserted, positioned and the scalp incision closed with some tension.

Custom Occipitgal Implant in Female result side view Dr Barry Eppley IndianapolisA custom skull implant for a flat back of the head offers the most predictable outcome with the lowest risk of complications or need for revisional surgery in my experience. Designing the implant shape and thickness that the scalp can tolerate is the ‘art’ in the process and that will differ somewhat for each patient. Some patients will find that the amount of augmentation may be less than they desire as a single stage procedure. If one desires much larger amounts of occipital augmentation, a two-stage approach can be done with a first stage scalp tissue expander.

Case Highlights:

1) Custom designed silicone implants are the most effective method for augmentation of the flat back of the head.

2) The size and thickness of a custom occipital implant is controlled by the incisional access and how much the scalp will stretch to accommodate the thickness of the implant

3) It has been my experience that 12mm to 15mms is as much implant thickness that can be placed on the back of the head.

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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