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.

April 19th, 2015

The Value of the Alar Rim Graft in Rhinoplasty


The shape of the nostrils and the overlying nostril rims has taken on increased interest in rhinoplasty surgery and its outcomes. Much of this interest in driven by patients who may after a rhinoplasty feel that they show too much of a nostril opening or have nostril asymmetry with one rim of the nostril higher than the other. Alar rim retraction can certainly be created from open rhinoplasty surgery from a variety of tip cartilage shaping techniques.

Some rhinoplasty patients also have a natural concavity to their alar rims or a propensity to it due to thinner or weaker lower alar cartilages. This natural tendency can be exaggerated after rhinoplasty surgery. Both for prevention of alar rim retraction and for improved aesthetics of the transition from the nasal base to the tip (prevention of alar rim concavity),  the alar rim cartilage graft has become an integral part of primary and secondary rhinoplasty surgery.

Alar Rim Grafts in Rhinoplasty Dr Barry Eppley IndianapolisIn the April 2015 issue of the journal Plastic and Reconstructive Surgery, an article on this topic appeared entitled ‘Dynamics of the Alar Rim Graft’. In this paper, the senior author reviewed 1,427 rhinoplasties performed of which 565 received alar rim grafts. (40%) In reviewing these cases it was noted that the use of alar rim grafts, which were once used almost exclusively in revisional rhinoplasty, had changed to a more frequent use in primary rhinoplasty surgery more recently. The benefits of such graft use were correction of nostril rim concavity and lengthening and widening of the nostril.

Alar Rim Graft Rhinoplasty Indianapolis Dr Barry EppleyThe technical details of the use of alar rim grafts were reviewed. The grafts can be taken from any cartilage source including the resected cephalic border of the lower alar cartilage or scraps left over from a septal graft harvest but the best (stiffest) grafts come from a good piece of thin septal cartilage or rib cartilage. The graft dimensions are usually about 15mms long and 2 to 3mms wide. The grafts are inserted through a small incision just under the nostril rim from which a small linear pocket is made along the rim. In closed rhinoplasties, the incision is anterior with the pocket made down to the base. In open rhinoplasties the incision is made closer to the base and the pocket dissected towards the tip. Either way it is important that the graft does not come too close to the tip so that it does not inadvertently widen it.

This small but elegantly conceived cartilage graft is an important element of rhinoplasty surgery whether it is a primary or revisional procedure. It is helpful to prevent nostril rim concavity and retraction deformities as well as to help lengthen and widen nostril shape.

Dr. Barry Eppley

Indianapolis, Indiana

April 19th, 2015

Product Review – Emend in Plastic Surgery for Nausea and Vomiting Prevention


While patients have many different fears about having surgery, one of the most common is postop nausea and vomiting afterwards. (PONV) While this is a concern regardless of the type of surgery, it is of paramount importance in cosmetic surgery because it is completely elective. For some this concern may even make them think more than twice about having surgery at all.

The patients that are at greatest risk of nausea and vomiting after plastic surgery are those patients that have a prior history of it. Also the risks are increased in those patients that are having longer operations, such as a facelift or Mommy Makeover for example. While anesthesiologists use a much more aggressive anti-emetic approach today, including the use of perioperative IV medications such as phenergan, zofran and steroids, it is not fool proof. Some patients will still have breakthrough PONV. Besides its uncomfortability, episodes of PONV cause elevated blood pressure which can induce bleeding and even hematoma formation.

Emend in Plastic Surgery for Nausea and Vomiting Prevention Dr Barry Eppley IndianapolisA newer medication, Emend (aprepitant), can provide an improved preventative approach to PONV. This drug has been approved in the U.S. since 2003 for the treatment of nausea and vomiting from chemotherapy in cancer patients. It works by an entirely different mechanism that other anti-emetic drugs being a Neurokinin 1 antagonist which blocks the neurokinin 1 receptor. Emend is also different in that it will not work if you are already suffering from nausea and vomiting. It is a preventative drug not a therapeutic one. It must be taken 6 hours prior to surgery to have an anti-emetic effect. In plastic surgeons that prophylactically provide it to their high risk patients along with conventional drugs, there is a near 100% prevention of PONV.

The only downside to the use of Emend is its relatively high cost, of around $50 per pill. But to those patients who have had PONV before, this is no doubt they would say it is well worth it.

Dr. Barry Eppley

Indianapolis, Indiana

April 18th, 2015

Counterfeit Botox in the U.S. Alert


Botox injection therapy is the single greatest pharmacologic agent in use today for non-surgical facial rejuvenation. It has been become so popular and used that patients talk about getting ‘Botoxed’…reminiscent of days when copying was known as ‘Xeroxing’. That is how you know your product has worked its way into the national lexicon when its name becomes used as a verb.

Fake BotoxWith such treatment popularity, competition is inevitable (which is good) but imitators may also emerge. (which for a drug can be very bad) Known as ‘Black Market Botox’ drugs that appears as the real Botox or try to be passed off as such have been known to occur. The FDA reports today that such compounds have been found in the U.S. and may be being used in some doctor’s office and clinics. This occurs when an unlicensed supplier who is not permitted by FDA regulations to ship or distribute products into the U.S. does so.  Offering seemingly similar effectiveness but at lower prices is the inducement for physicians to purchase and use it. Patients would have no idea that an unlicensed drug may be given to them during their treatments.

Botox Injections Indianapolis Dr Barry Eppley IndianapolisSince these compounds have not been manufactured according to FDA standards, there is no assurance that they are safe or effective. How can one tell if their ‘Botox’ is real? For physicians it can be determined by the packaging and the actual vial that contains the compound. On real Botox as manufactured by Allergan the active ingredient known as  onabotulinum toxin A is listed on the outer carton as well as on the glass bottle. With the fake compound, the active ingredient is listed as botulinum toxin type A is listed on the outer carton and glass bottle. Also on the fake product the glass bottle may be missing any lot numbers.

For patients determining that they be given a counterfeit product may be impossible to tell. Very low advertised prices per unit or extraordinary specials may be a clue. Injections done in non-medical settings by dubiously qualified injectors may be another tip off. Any change in the effectiveness of one’s ‘traditional’  Botox treatment may also raise some suspicion.

Dr. Barry Eppley

Indianapolis, Indiana

April 14th, 2015

Case Study: Sliding Genioplasty for Lower Facial Elongation


Background: A sliding genioplasty is a well known and historic procedure for changing the shape of the chin. It was originally described in the 1940s but has evolved considerably due to the use of rigid fixation using plates and screws. While once clever osteotomy designs and wire fixation methods were used for stabilization of the bone segments, which limits how much the chin position could be changed, plate and screw fixation now makes virtually any bony chin change possible.

Sliding Genioplasty Indianapolis Dr EppleyFor chin augmentation, the chin implant is often compared to the sliding genioplasty as creating similar effects. But the reality is that this is only partially true and they are only comparable when it comes to pure horizontal movements as seen in the profile view. Vertical and width (narrowing) changes can not be done with an implant. (although newer vertical lengthening chin implants have recently become available)

The real benefits for a sliding genioplasty are when vertical elongation of the chin is needed and when the amount of chin advancement desired exceeds that of which standard implants can achieve. This would be particularly useful in women who can aesthetically tolerate a more narrow chin as it comes both forward and down. The other benefit for a sliding genioplasty in these more substantial chin changes is that it ‘carries’ the soft tissue of the chin pad with it and does not create a devascularizing effect due to maintaining most of the soft tissue attachments (and resultant perfusion) to the bone.

Case Study: This 26 year-old female had a short chin in both horizontal and vertical dimensions. Her lower facial height was disproportionate to the rest of her face. As a result, she appeared to have a full neck/double chin.  She knew she wanted her chin augmented but was just not sure how it should be done.

Sliding Genioplasty result side viewSliding Geniop[lasty result oblique viewUnder general anesthesia, she underwent an intraoral sliding genioplasty. A low horizontal bone cut was done and the chin was advanced 16mm forward and 8mms downward. This was the maximum amount of chin bone movement that could be done while still maintaining some bone contact between the segments. Rigid fixation was achieved by a titanium step plate and screws. The bone gap (step between the upper and lower bone segments was filled with demineralized bone particles. The mentalis muscle was resuspended at closure.

Sliding Genioplasty result front viewThe vertically opening sliding genioplasty can help make the lower face more proportionate by making bringing it forward and down. This will make the jawline have more of a V-shape and will also help get rid of a double chin problem due to lack of bony projection.

Case Highlights:

1) A sliding genioplasty is historically the only chin procedure that can provide both horizontal and vertical elongation of the chin. (custom made implants can now do that also)

2) A vertically opening sliding genioplasty with horizontal advancement will make the chin more narrow as a result of these bony movements.

3) Unless the bony chin movements are extreme, bone grafting of the interpositional gap between the chin segments is not necessary. Even when needed demineralized bone substitutes can be successfully used.

Dr. Barry Eppley

Indianapolis, Indiana

April 13th, 2015

Product Review – Exilis Elite for Cellulite Treatment


Cellulite is a well recognized aesthetic skin condition that occurs most commonly in women and involves the buttocks and thighs. The cottage cheese appearance is recognized today to be the result of compartmentalized fat hypertrophy and the contraction of dermal-fascial bands in the involved regions. New device based treatments continue to emerge for its treatment that either focus on fat reduction, fascial release or both.

Exilis Skin Tightening Indianapolis Dr Barry EppleyExilis is a monopolar radiofrequency device that is used to heat the skin, resulting in collagen remodeling and skin tightening. It was first introduced in early 2011 after FDA clearance for the treatment of loose skin and body contouring. It has proven to be a valuable non-surgical treatment for reducing loose skin and wrinkles on the face and body.

Exilis Elite Dr Barry Eppley IndianapolisIn February 2015 the FDA has approved the use of Exilis for the temporary reduction in the appearance of cellulite. Using a new treatment protocol that can effectively target the fat underneath cellulite involved skin that helps give it its dimple lumpy external appearance, temporary improvement in the appearance of the skin is obtained. It takes multiple treatments, usually four to six, spaced several weeks apart to get the full effect. Full results can take up to three months after treatment.

Exilis Elite joins a growing number of devices for cellulite that offers non-surgical treatments of an aesthetic problem that defies any universally effective solution.

Dr. Barry Eppley

Indianapolis, Indiana

April 12th, 2015

PRP Injections for Periorbital Hyperpigmentation


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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

April 11th, 2015

Case Study – Tongue Tie Release in Adults


Tongue Tie Release Surgery Dr Barry Eppley IndianapolisBackground: Tongue tie or ankyloglossia is a well recognized congenital anomaly of the tongue. It results from a restriction or lack of development of the lingual frenulum which is a membranous attachment from the underside of the tongue to the anterior floor of the mouth. When the frenulum is short the tip of the tongue’s motion is limited, often not allowing the tongue to move past the edges of the lower teeth.

There are numerous potential functional limitations from a severe tongue tie from eating, speech and dental development. While somewhat controversial for some, a tongue tie release or ankyloglossia surgery is often done early in life to give the tongue full range of motion and to prevent any subsequent functional limitations. This procedure of often combined as part of other minor surgeries as it requires an anesthetic given the very young age of the patient.

Seeing an adult with a significant tongue tie is rare since they are almost always released early in life. The main reason an adult would finally release it is if they desired greater tongue mobility, particularly that of tongue protrusion. This can translate into an improved ability to clean the teeth with tongue during and after eating. The second benefit would be an improved ability to use the tongue during intimacy.

Case Study: This 24 year-old female had long wanted to have her congenital tongue tie released. She has never been able to stick her tongue out and had always felt her ‘forked tongue’ was unusual.

Adult Tongue Tie Release Tongue Mobility result Dr Barry Eppley IndianapolisAdult Tongue Tie Release result Dr Barry Eppley IndianapolisUnder local  anesthesia, her tongue tie was released at its base just behind the sublingual ducts. It was released by needlepoint electrocautery back along the floor of the mouth to the base of the tongue. In a near V-Y mucosal closure pattern, the mucosal edges were closed with small dissolveable interrupted sutures. The increase in her tongue’s range of motion was immediate and considerable as can be seen in the above before and after pictures.

Tongue Mobility after Tongue Tie Release Dr Barry Eppley IndianapolisTongue tie release in adults is just as effective in adults as in babies and infants. Its effects are immediate and there is little if any recovery from this simple floor of the mouth procedure.

Case Highlights:

1) Significant tongue tied in adults is fairly rare due to its tongue mobility restrictions and earlier treatment for release.

2) Tongue tie release surgery in adults can be done under local anesthesia as an office procedure in adults.

3) The simplest and most effective tongue tie release surgery is a V-Y advancement technqiue.

Dr. Barry Eppley

Indianapolis, Indiana

April 8th, 2015

Case Study – Silver (Older Women) Breast Augmentation


Background: Breast augmentation continues to enjoy widespread popularity and literally is a procedure for all ages today. While the majority of women getting breast implants is still largely under the age of fifty (50), the above fifty group who are willing to have the surgery is growing. While once it seemed rare to have women in their sixties and seventies  choosing to get breast implants, so called silver breast augmentation, it is not uncommon to have such requests today.

Silver Breast Augmentation Dr Barry Eppley IndianapolisBeyond any health or medical issues, there is no physical reason why a woman of any age can not get breast implants. Such procedures have been performed for years for the non-elective reason of breast reconstruction after cancer removal. Often these operations are more invasive and physically stressful than a less complicated aesthetic breast augmentation even though two breasts are treated for cosmetic enhancement while one may only be treated for a malignancy.

The one consideration that is more common in the older vs the younger breast augmentation patient is that of tissue quality and amount. Age, pregnancies and the long term effects of gravity often leave the older breast implant patient with little glandular tissue, variable amounts of sagging and thinner skin. This  is particularly true in those older women who have had good lifelong weight control and a thinner body habitus.

Case Study: This 62 year-old female desired implants to restore some lost breast volume (actually have more than she ever had) and give her body a rejuvenated look. She had some mild breast sagging but not enough to justify any type of a formal breast lift nor did she want the resultant breast scars either.

Silver Breast Augmentation result front view Dr Barry Eppley IndianspolisSilver Breast Augmentation result obique view Dr Barry Eppley IndianapolisUnder general anesthesia, she had high profile silicone gel breast implants (400cc) placed through inframammary incisions. Her after surgery results showed a much fuller upper pole of the breasts and a nipple position that was not unduly low. It was not centered on the breast mound but its location justified the presurgical decision to not do any type of breast or nipple lift.

Breast augmentation at age 60 years or older can be successfully down with no greater recovery than that of a woman decades younger. Older women may also accept less of an ideal breast shape and nipple position for the benefits of what breast implants alone can achieve.

Case Highlights:

1) Breast augmentation in ‘older’ women can be performed as successfully as in younger women.

2) Silver breast augmentation takes into consideration the degree of breast sagging and often may require a breast lift performed concurrently.

3) Breast augmentation in the more ‘aged’ breast may be more tolerant of accepting somer residual sag or lower nipple position on the augmented mound.

Dr. Barry Eppley

Indianapolis, Indiana

April 6th, 2015

Technical Strategies – Intraoperative Pain Control Techniques in Migraine Surgery


Treatment of very specific types of migraine headaches can be successfully done by extraforaminal decompression techniques. This is especially true for the migraine trigger site of the supraorbital nerve. By removing all of the muscle from around the neurovascular bundle (and occasionally removing some foraminal bone and ablating the artery) a decrease in the severity and frequency of migraine headaches can be potentially achieved.

But despite the procedure’s ultimate success at migraine reduction, very often migraine surgery creates an immediate postop migraine event. This is not surprising given the trauma that results in and around the nerve from its decompression. While such a migraine ‘reaction’ does not occur in every patient, it certainly is distressing to those in which it does. In the short term it is very much like ‘adding insult to injury’.

Marcaine Injections in Migraine Surgery Dr Barry Eppey IndianapolisSeveral intraoperative techniques can be useful for reducing the risk of an immediate after surgery migraine attack. After the induction of anesthesia, supraorbital nerve blocks are done using a  0.25% Marcaine and epinephrine (1:200,000) solution. (bupivicaine) This will block nerve sensations in the forehead and create a profound but temporary numbness of the supraorbital nerve’s anatomic distribution. These effects will wear off in 24 hours.

Endoscopic Supraorbital nerve decompression with gelfoam spongeAnother intraoperative technique is to treat the base of the supraorbital nerve with steroids after it has been decompressed. This is best done by soaking a dissolveable collagen sponge with Kenalog (triamcinolone) and wrapping it completely around the now visible nerve branches. This will have a calming effect on the nerve that will last well beyond that of the local anesthetic Marcaine.

Dr. Barry Eppley

Indianapolis, Indiana

April 6th, 2015

Case Study – Otoplasty Reversal Using An Interpositional Metal Spacer


Otoplasty left ear side view result Dr Barry Eppley IndianapolisBackground: Otoplasty for protruding ears is primarily done by cartilage reshaping/repositioning. Whether it is the placement of antihelical or concha-mastoid sutures, the ear is ‘pulled back or ‘pinned’ by cartilage manipulation. The use of these suture techniques is primarily an art and how many are used, placed and their degree of tightening is a matter of intraoperative judgment.

Despite the plastic surgeon’s best intent in some cases, the ears may not be pulled back far enough or may be pulled back too far. Undercorrection, whether done early or late, is an easier problem to improve by the placement of additional sutures. Overcorrection of the protruding ears, however, is a different matter. If treated early (within weeks or a month or two from the initial surgery), release of some of the sutures or replacement of them can be effective. Once scar has formed between the postauricular cartilage surfaces and/or the cartilage has lost memory, suture release will not create an otoplasty reversal. (partial)

A delayed  otoplasty reversal requires an interpositional graft to be placed between the released cartilage folds. While effective, few patients want to have a cartilage graft harvested to help the ears sit back out three to five millimeters. Ideally the cartilage graft should come from the end of one of the free floating ribs…a concept that even makes it less appealing.

Case Study: This 30 year-old female had an original otoplasty severn years ago that was undercorrected. He then had an otoplasty revision to set the ears back further. This resulted in an overcorrected problem  He had a third otoplasty procedure years later to bring the ears out further but it was not successful. To the best of his knowledge it was procedure to release the sutures.

Reversal Otoplasty Plate Dr Barry Eppley IndianapolisUnder local anesthesia, the central portion of his postauricular incisions was reopened and the scar tissue between the cartilage folds released. A small titanium mesh plate (1mm profile) was cut into a small clip-like shape and bent at 90 degrees. It was then wedged in between the released cartilage folds and sutured into placed. The skin incision was closed with small dissolveable sutures.

Reversal Otoplasty Right Ear results Dr Barry Eppley IndianaplisReversal Otoplasty Left Ear results Dr Barry Eppley IndianapolisHis immediate after surgery pictures showed a modest (3mm) increase in his ear projection which was maintained. The push of the metal plate maintained the cartilage position as new scar tissue was formed.

Partial otoplasty reversal can be successfully done using a small metal insert to hold the ear out. This effectively replaces the need for a cartilage graft as an interpositional spacer.

Case Highlights:

1) An otoplasty is said to be overcorrected when the helical rim is pulled behind the antihelix.

2) Partially reversing an otoplasty can not be done secondarily after the first few months after surgery by releasing the original cartilage sutures.

3) A delayed reversing otoplasty requires a method to hold the cartilages apart of which a small metal plate or ‘spring’ can be effective.

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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