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.

February 19th, 2016

Case Study – Non-Orthodontic LeFort 1 Advancement

 

Background: Treatment of a midface deficiency is most commonly done by moving the upper jaw forward. Done by making a horizontal bone cut just above the roots of the teeth, the upper jaw is brought forward into a new horizontal position. This well known facial bone procedure is the LeFort I osteotomy and has been the backbone of everyday orthognathic surgery for the past fifty years.

LeFort I OsteotomyCommon facial osteotomy procedures, such as the Lefort I, fall under the generic category of orthognathic surgery. As implied in its name, this involves the jaw bones and how the teeth meet or interdigitate. One of the essential aspects of this type of surgery is the need for before and after surgery orthodontics. Getting the teeth prepared so that they will meet perfectly once the facial bones are moved into their new position is not only of functional significance but often the definitive measure of the success of the procedure.

But not every patient who is in need of a Lefort I osteotomy, or any form of orthognathic surgery, is always a good candidate for orthodontic therapy. Due to compliance issues or the inability to tolerate the intraoral manipulations of orthodontic appliances, consideration can be given to doing the surgery ‘braces free’. This is done with the understanding that the goal of an ideal occlusal interdigitation is not achievable.

Case Study: This 15 year-old teenage female had a severe midface deficiency and upper airway obstruction due to a limited nasal airway. Due to a developmental delay, the application of orthodontic appliances and therapy was not possible.

LeFort 1 Advancecment Dr Barry Eppley IndianapolisLeFort 1 Advancement oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, a one-piece LeFort 1 advancement was performed with an advancement of 11mms. The goal was to get the anterior maxillary incisor teeth to sit in front of the mandibular incisor teeth in terms of degree of advancement. It was accepted that the premolar and molar occlusion would be far from ideal. Rigid 1.5mm plate and screw fixation was applied. No after surgery jaw wiring or intermaxillary fixation was used. She was allowed to have full jaw motion after surgery with a diet restricted only by her comfort.

While any form of orthognathic surgery (maxillomandibular osteotomies) is ultimately judged by a specific measurable outcome (the occlusion), there are other facial benefits that can supercede how the teeth interdigitate…particularly when they do to fit that well initially anyway.

Highlights:

1) A maxillary advancement (LeFort I osteotomy) can be done in rare circumstances without the need for presurgical orthodontics.

2) A LeFort I osteotomy produces well known midface aesthetic benefits including profile enhancement and improved nasal airway breathing.

3) A non-orthodontic LeFort I advancement is a skeletal improvement procedure, not a dental one.

Dr. Barry Eppley

Indianapolis, Indiana

February 15th, 2016

Technical Strategies – Head Widening Implants

 

The width of the side of the head  is controlled by the shape of the temporal bone and the thickness of the temporalis muscle, all located above the ear. While many think the bone is the main contributing factor, the thickness of the temporalis muscle should not be underestimated. By CT scan measurements it can be seen that the temporalis muscle usually makes a bigger contribution than that of the bone to the width of the side of the heasd.

Regardless of the anatomic makeup of the width of the head, widening the narrow head must be done by either onlay augmentation of the bone (submuscular) or onlay augmentation of the muscle. (subfascial) Which implant location is best depends on whether the augmentation involve just the posterior temporal region (above the ears) or also the anterior temporal region as well. (by the side of the eye)

Head Widening Implants (anterior and posterior temporal implants Dr Barry Eppley IndianapolisHead Widening Implants (incision and subfascial dissection) Dr Barry Eppley IndianapolisMost head widening implants augmentation include both the anterior and posterior temporal regions. This can be accessed through a single 4cm incision placed in an intermediate location in the temporal hairline. Using a subfascial incision and pocket dissection, extended anterior and larger posterior temporal implants can be placed through the same point of temporal incisional access.

Head Widening Implants (implant placement and subafscial closure) Dr Barry Eppley IndianapolisHead Widening Implants (incision closure) Dr Barry Eppley IndianapolisAfter the placement of both anterior and posterior temporal implants in the subfascial pockets, the fascia os closed over the them. The skin closure is done in a two layer fashion with resorbable sutures.

Head widening or complete temporal augmentation can be done through a single small temporal incision. Two implants are needed to increase the volume of both the anterior and posterior temporal regions.

Dr. Barry Eppley

Indianapolis, Indiana

February 14th, 2016

Case Study – Female Calf Implants

 

Background: The calf or gastrocnemius muscles are a compact and powerful set of lower leg muscles that run from the knee to just above the ankle. It is a bipennate musclke with two known heads. The outer or lateral head starts at the lateral condyle of the femur while the inner head starts from the medial condyle of the femur. The two heads of the muscle join up about midway between the knee and ankle to form a common tendon with the soleus msucle. This common tendon then extends down inferiorly  to fix to the heel and is known as the Achilles tendon.

gastrocnemius muscle anatomyWhen placing calf implants the anatomy of the aforementioned muscles and tendon is critical. Calf implants are always placed in the subfascial location to sit on top of the muscle. But the subfascial dissection can not extend below the most inferior portion of the muscle where it joins the tendon of the soleus muscle. In the upper half of the lower leg the soleus muscle lies under the gastrocnemius muscles. But as the soleus muscle emerges more superficial at the bottom edge of the gastrocnemius muscles, the overlying fascia becomes very adherent and hard to dissect under.

Most women who seek calf augmentation have a different agenda than that of some men. Women are usually concerned about having a very skinny lower leg that has no definition. (so called ‘chicken legs’) They are looking for some sort of an inner calf ‘bump’ that breaks up an otherwise straight line from the knee to the ankle.

Case Study: This 35 year-old Asian female has long been bothered by the shape of her legs. They were very skinny and has very small calf muscles with a small circumferential calf measurement.

Calf Implant Sizing Dr Barry Eppley IndianapolisIntraoperative Calf Implant Sizing Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, a 3.5 cm incision was made in the inner half of the popliteal skin crease. The gastrocnemius fascia was identified, incised and subfascial dissection down with a long broad flat instrument The dissection was done down to the bottom of the calf muscle which was marked beforehand by having her stand on her toes. The standard medium sized calf implants were too long for the length of her gastrocnemius muscles. The calf implants were trimmed to a proper length and then inserted in the subfascial pocket. The fascia was closed over by a fat flap and the skin closed with resorbable sutures in two layers.

Female Inner Calf Implants result front view Dr Barry Eppley IndianapolisFemale Inner Calf Implants result back view Dr Barry Eppley IndianapolisCalf implants in women are designed to create some muscle enhancement in the inner lower leg so it is not just a straight line. In this patient medium calf implants were used whose length needed to be shortened. In hindsight perhaps large calf implants with a wider width would have produced a more significant result. Larger calf implants are longer but shortening the standard length of medium calf implants was needed anyway.

Highlights:

1) Calf implants can be used to augment either in the inner or outer gastrocnemius muscles

2) Most women want to improve the shape of the skinny lower legs through medial or inner calf implants.

3) Inner calf implants are placed in a subfascial plane on top of the muscle through a popliteal crease skin incision.

Dr. Barry Eppley

Indianapolis, Indiana

February 14th, 2016

Technical Strategies – Extended Temporal Implants

 

Temporal implants have become the surgical approach to the treatment of temporal hollowing.  They offer a rapidly performed permanent solution that eclipses the temporary and inconsistent effects of synthetic fillers and fat injections. These implants are placed in the subfascial location on top of the temporalis muscle through a small vertical or obliquely oriented incision back in the temporal hairline.

As the use of temporal implants has increased, new styles have emerged. The initial temporal implant design was designed to treat the deepest part of the temporal hollows by the side of the eye. These implants only went up about as high as the lateral brow bone.

Extended Anterior Temporal Implant Dr Barry Eppley IndianapolisBut as more experience with temporal implants has evolved, it become clear that the extent of bothersome temporal hollowing can extend all the way up to the side of the forehead. (anterior temporal line) This has led to an extended style of temporal implants that provides some augmentation much higher than the standard style. (up to 6.5 cm vertical height from the zygomatic arch)

Temporal Implants Incision and Insertion Dr Barry Eppley IndianapolisWith such a larger temporal implant, the concern would be that a much larger incision would be needed for its placement. To avoid more than a 3 cm to 3.5 cm incision, the key is to make the subfascial pocket through a small incision. This is easy to do with instruments in a blind fashion. Then the implant can be inserted lengthwise in a rolled fashion. Once making its way through the small incision, the implant is unfurled and rotated into the proper position.

Larger styles of temporal implants can still be inserted through relatively small temporal hairline incisions. This makes the appeal of temporal implants for larger areas of temporal hollowing equally appealing as smaller amounts of temporal hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

February 14th, 2016

Platelet Rich Plasma (PRP) Injections for Hair Loss

 

Hair loss due to genetics in men and women is known as  androgenetic alopecia and is extremely common. A wide variety of methods have been used to treat this type of hair loss of which the pharmacologic treatments have been the most successful.  At the least they are the most documented by scientific scrutiny having to pass through FDA clinical trials.

The drugs Oral finasteride (Propecia) and topical minoxidil (Rogaine) each have proven to slow or cease hair loss and offer some variable amounts of hair regrowth. Side effects, however, cause some patients to avoid their use or eventually cease using them.

Platelet Rich Plasma injections Indianapolis Dr Barry EppleyMore recently another type of stimulating agent, platelet-rich plasma (PRP), has been applied to treat hair loss. Since this is a natural concentrate from the patient’s blood, it does not require FDA approval to use for any medical purpose. Thus no FDA-sanctioned clinical trial has ever been done on PRP for hair loss and its benefits have largely been anectodal.

PRP injections for hair lossIn the Online First January 2016 issue of the European Journal of Plastic Surgery, the article entitled ‘Management of Androgenetic Alopecia: A Comparative Clinical Study between Plasma Rich Growth Factors and Topical Minoxidil’ was published. The purpose of this clinical study was to compare the effectiveness of plasma rich plasma (PRP) versus topical minoxidil treatments in genetically-driven hair loss patients. Almost 400 patients (379 to be exact) were treated with either platelet rich plasma or minoxidil. Diagnostic trichograms were done prior to and 4 months after treatment to analyze the anagen/telogen hair change improvement.

PRP scalp injectionsTheir results shows that platelet rich plasma treated patients had higher anagen hair increase improvement compared to minoxidil treated patients. (6.9 vs 4.6, p?<?0.05). Telogen hair decrease improvement was also higher in the platelet rich plasma treated group. (5.7?vs 2.6?, p?<?0.05). Photographs showed an overall improvement in both volume and quality of hair for both types of treatments. No adverse effects for either treatment were seen. The authors conclude that platelet rich plasma is a safe and effective treatment for androgeneic alopecia and offers improved results over that of topical minoxidil.

PRP Hair Loss Treatments Dr Barry Eppley IndianapolisThis is the first study that has demonstrated in a large series of patients the benefits of platelet rich plasma injections in the treatment of hair loss. Even at its worst, one can conclude that platelet rich plasma is at least as effective as minoxidil. The benefits of PRP hair loss treatment is that it is a single treatment session and has no side effects. Its negatives are that it is much more expensive than minoxidil and would likely have to be repeated every 4 to 6 months to maintain its effects. There is no information currently that would indicate as to how many times PRP injections would be need to be repeated to majntain or improve hair growth.

Dr. Barry Eppley

Indianapolis, Indiana

February 13th, 2016

Custom Skull Implant for Adult Plagiocephaly Correction (Case Study)

 

Background: Plagiocephaly or craniofacial scoliosis is a well known craniofacial deformity that truly affects the whole craniofacial skeleton. The most well known component of it is the flattening of the back of the head which for many patients may be the most severely affected area. At the least treating the asymmetric back of the head is the number one priority in its treatment in adults.

The shape of the back of the head becomes very apparent for short hairstyles or when one shaves their head. The exposure of the back of the head is more common in men for these reasons either by an elective hairstyle or when one is losing or has lost their hair. But it also can affect women who, despite having more hair, may be equally self-conscious about it. They may avoid being seen coming of the shower with their hair wet or when swimming due to their being a flat side of the back of the head.

Unlike in infants, correction of adult occipital plagiocephaly is done by onlay bone augmentation. There are numerous methods of building up the bone of the skull by various synthetic materials. Having used all of them, the best method for occipital augmentation is the creation of a custom skull implant made from a 3D CT scan. No hand created intraoperative method can match the symmetry and smoothness of the implant contours created by computer designing.

Adult Occipital Plagiocephaly Custom Skull Implant Design Dr Barry Eppley IndianapolisCase Study: This 30 year-old Asian male has long been bothered by the shape of his head, particularly that of the back. The right side was noticeably flatter than that of the left with the right ear more anteriorly located than the left. There were some forehead asymmetry but this was not a priority. Using a 3D CT scan, a computer-generated right occipital implant custom skull implant that matched the left side perfectly. The maximum thickness of the implant over the most deficient occipital ares was 8mms.

Adult Occipital Plagiocephaly Skull Implant Correction Dr Barry Eppley IndianapolisAdult Occipital Plagiocephaly Skull Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, a 5 cm horizontal skin incision was made in the low occipital scalp location. Wide subperiosteal undermining was done 2 cms beyond the border of the implant location as marked on the scalp. The implant was prepared for insertion by the placement of multiple perfusion holes through it using a 3mm dermal skin punch. The implant was inserted and positioned based on its shape and location on the 3D design images. The scalp was closed in multiple layers using resorbable sutures.

Adult Occipital Plagiocephaly Custom Skull Implant result intraop Dr Barry Eppley IndianapolisAdult Occipital Plagiocephaly Custom Skull Implant result intraop side view Dr Barry Eppley IndianapolisThe effect of a custom skull implant is both immediate and profound. Besides getting the right shape and thickness of the implant, it must be inserted through an incision that is as small as possible. This makes the final definitive argument for a custom silicone implant which allows itself to be rolled and inserted through an incision that is usually about 1/3 in 1/3 in length as the most narrow width of the implant.

Highlights:

1) Plagiocephaly is most commonly associated with a flattening of one side of the back of the skull.

2) An important component of correction of plagiocephaly in adults is augmentation of the flat side of the back of the head.

3) The best method for correction of the unilateral occipital plagiocephaly in adults is a custom skull implant.

Dr. Barry Eppley

Indianapolis, Indiana

February 13th, 2016

Case Study – Asian Rib Graft Rhinoplasty

 

Background: Rhinoplasty often involves augmentation maneuvers to raise the profile of the nose. This is true in many ethnic rhinoplasties, particularly Asians noses. With short nasal bones and a flatter dorsum, the entire profile of the nose can be more recessed. A low dorsum is often associated with a flatter and broader nasal tip as part of the overall underdevelopment of the nasal structures.

In Asian rhinoplasty, a more refined and prominent nose involves augmentation of the dorsum (bridge) as well as that of the nasal tip. The entire profile of the nose needs to be built up from the radix down to the tip. The tip needs to be elevated with a longer columella and nostrils that are not overly wide.

Creating these changes in Asian rhinoplasty requires increased structural support. This can come from using the patient’s own natural cartilage or that of a synthetic implant. There are surgeons who are advocates of both types of nasal augmentation methods. By far synthetic implants are more widely used because of their simplicity and lack of the need for a donor site. Rib grafts require a very motivated patient who can tolerate the donor site and a surgeon who is experienced in how to shape the graft with a low incidence of warping and graft asymmetry.

Case Study: This 19 year-old Asian female wanted to augment her flat nose with little profile. She needed little time to opt for a rib graft given her young age and the desire for a nasal augmentation method that would pose no long term risks of infection or extrusion.

Asian Rib Graft Rhinoplasty result side viewUnder general anesthesia a portion of ribs #9 and an in situ portion of #8 was harvested from the right subcostal margin using a 3.5 cm incision. Through an open rhinoplasty a dorsal graft was carved from the portion of rib #8. A columellar graft was shaped from #9 including an infralobular tip graft as an overlay on the dome to further project the tip.

Asian Rib Graft Rhinoplasty result oblique viewA rib graft remains as a mainstay for many ethnic rhinoplasties where significant nasal augmentation is needed. There are numerous ways to use the rib graft as a dorsal onlay, a septal extension graft to tip projection methods. With the exception of the dorsum, a rib graft is used exclusively as a carved solid graft of various dimensions. On the dorsum it can be either a carved solid block or diced and wrapped into a moldeable ‘putty’.

The solid carved dorsal rib graft can be effective in dorsal augmentation when the rib harvested is of sufficient length and not unduly curved. Unfortunately this is not that commonly encountered  and careful carving may not always prevent the thinner end of the graft from developing some slight curvature or asymmetry. When in doubt the rib graft should be diced and wrapped in Surgical or fascia.

Highlights:

1) Asian rhinoplasty usually involves augmentation of the bridge (dorsum) and the tip of the nose.

2) The primary augmentation method of the dorsum in Asian rhinoplasty could be a synthetic implant or a rib graft.

3) The rib graft in rhinoplasty can be used as either a carved solid cartilage graft or wrapped diced cartilage.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2016

The Body Lift or Extended Tummy Tuck

 

A tummy tuck is a well recognized body contouring operation because it has been around for many years. It is generally perceived as a hip to hip excisional and tightening abdominal operation as it only affects the front side of the torso. The term ‘body lift’ however is less well defined in the eye of the patient and can be open to interpretation.

It is recognized that a body lift is more than just a tummy tuck but how much more can be debated. It is an operation that is closely associated with managing the abundant loose and hanging tissues in the extreme weight loss patient, whether the weight loss was surgically induced or not. In this context, a body lift is a circumferential or 360 degree operation removing tissues completely around the waistline.

Body Lift Dr Barry Eppley IndianapolisBut a modification of the body lift can be used in non-weight loss patients. Rather than going completely around the waistline or 360 degrees, the excision extends about halfway between the spine and the side of the waist. (270 or 300 degrees) This captures more loose skin that might otherwise not be adequately addressed by liposuction. This extended skin excision is best done in patients with poor quality skin with little contractile ability around into the back, when a large skin rolls extends into the back and/or when sagging skin exists over the outer thighs.

In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was printed entitled the ‘Cosmetic Body Lift’. In this paper the author reviewed 72 patients over a ten year period who had a body lift defined as a  270 degree extended lipoabdominoplasty. (tummy tuck) The amount of liposuction aspirate removed was just over 3,000cc. Complications included a near 3% incidence of seroma (drains were used),  a 4% infection occurrence, and skin necrosis in 4%.  No hematomas occurred. One patient developed a deep vein thrombosis. (DVT) Secondary revisions were done in 18%

Extended Tummy Tuck of Body Lift Indianapolis Dr Barry EppleyThis series demonstrates that the body lift procedure in non-weight loss patients can be done safely and with a similar low rate of complications as that of standard tummy tuck. The critical question for most patients who may benefit from having this ‘bigger’ tummy tuck is whether the extra scar length is perceived as a good trade-off.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2016

Case Study – Custom Occipital Implant with Occipital Knob Reduction

 

Background: Flattening of the back of head can occur on one side or both sides for congenital reasons. When it occurs on just one side of the back of the head it is known as occipital plagiocephaly. It is not, however, just simple limited flattening of one side of the occipital bone. It is well known to be more of an overall twisting of the skull where numerous other craniofacial areas are affected as well. The opposite side of the back of the head, the ipsilateral ear and even the forehead can be altered based on the severity of the deformity.

By far and away the flat side of the back of the head is always the patient’s primary aesthetic skull shape concern. I have used every available onlay cranioplasty material to build up the flat side of the head. The custom skull implant approach using the patient’s 3D CT scan has proven to be superior for a variety of reasons. The exact shape of the deformity correction is determined before surgery, smooth edges of the implant around its perimeter are assured and the implant can be inserted through a small incision due to its flexibility. Because of these benefits it also shortens the time to perform the surgery.

Custom Skull Implant and Occipital Knob Reduction Incision Marking Dr Barry Eppley IndianapolisCase Study: This 26 year-old male had long been bothered by the shape of the back of his head. His right side was flat and this was very visible to him since he shaved his head. He also had a moderately sized midline occipital knob which has no known association with occipital plagiocephaly. The area of the implant placement, the occipital knob location and the placement of the horizontal scalp incision was marked on his scalp before surgery.

Custom Skull Implant placement intraop Dr Barry Eppley IndianapolisUnder general anesthesia he was placed in the padded prone position which is the only way to perform occipital augmentation when coming from a low incision. Through a 9 cm skin incision, subperiosteal scalp flaps were raised over the location of the implant superiorly and inferiorly down to the occipital knob. The custom occipital implant had multiple perfusion holes made to create through and through tissue ingrowth from the scalp down to the bone into and around the implant after surgery as it healed.

Custom Skull Implant and Occipital Knob Reduction incisional access Dr Barry Eppley IndianapolisThe custom occipital implant was rolled and inserted through the incision. Once fully inserted and using a preoperative midline mark on the implant, all edges were unfurled to remove all visible edges of the implant and have it lay completely flat. On the bottom side of the incision, the occipital knob was completely burred down to the level of the surrounding occipital bone.

The scalp incision was closed in layers with resorbable sutures. No drain was used. The expected immediate change in the shape of the back of his head was seen. Prior to the placement of a head dressing, greater occipital nerve blocks were done using a long acting local anesthetic. (Marcaine)

Custom Skull Implant and Occipital Knob Reduction result left oblique view Dr Barry Eppley IndianapolisCustom Skull Implant and Occipital Knob Reduction results side view Dr Barry Eppley IndianapolisCustom Skull Implant and Occipital Knob Reduction result right side view Dr Barry Eppley IndianapolisAt just one day after surgery, the improvement in his head shape could be seen. Equally importantly, and why I post a one day after surgery picture (only the incision is taped) is that he has no significant bruising and very acceptable swelling. This is partly due to that it is an augmentation procedure where less swelling is always seen and that the tight tissues of the scalp do not allow for large amounts of swelling with limited scalp flap undermining.

Highlights:

1) Congenital occipital plagiocephaly create a visible flattening on one side of the back of the head.

2) One-sided occipital augmentation is most predictably done using a custom occipital skull implant from a 3D CT scan.

3) A custom occipital implant is best introduced through a low horizontal scalp incision on the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2016

Diced Cartilage Graft Rhinoplasty (Turkish Delight)

 

Significant augmentative rhinoplasty of the dorsum usually poses a choice between a synthetic implant and a rib cartilage graft. When choosing a rib cartilage graft, the options are to use it as a carved solid graft or to dice it and assemble it as a moldable wrapped cartilage graft. Introduced back in 1989, a finally diced cartilage graft became known as a ‘Turkish Delight’ because of its conceptual introduction by Turkish plastic surgeon.

Diced Cartilage Graft Rhinoplasty Indianapolis Dr Barry EppleyThe original technique description was to dice the cartilage graft into 0.5 to 1mm cubes and then wrap it with resorbable Surgicel collagen mesh. This original rhinoplasty grafting technique has been modified over the years by others using the patient’s own fascia instead of Surgical and moistening the small cartilage cubes with PRP. (platelet rich plasma)

In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘ Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty: 25 Years of Experience’. The original developer of this rhinoplasty cartilage grafting technique summarized his experience with it in close to 10,000 patients over a 25 year period. The patients reviewed were anywhere from 4 to 25 years out from their initial surgery. Both primary (7700) and secondary (2300) rhinoplasties had the cartilage grafting technique used. They report very low complication rates with its use including less than 1% incidences of prolonged swelling, overcorrection and resorption. They reported no infections or graft show over the short or long term followup.

Surgicel Diced cartilage Grafts in rhinoplasty Dr Barry Eppley IndianapolisParticulating a cartilage graft  for nasal implantation into small particles predictably eliminates the issue of graft visibility. The controversial aspect of the diced cartilage graft technique is the material used to contain. Surgicel is the original mesh wrap and is well known as a resorbable hemostatic material. It is made of an oxidized cellulose polymer (polyanhydroglucuronic acid) derived from plant fibers. It works by absorbing fluids which causes platelet plug formation to stop bleeding. The plant cellulose breaks down once it becomes wet and this results in a more acidic pH around it, giving it in contact with moisture which lowers the pH (more acidic). This gives Surgicel a bacteriostatic property. The cellulose material is rapidly eliminated, initially by absorption of the sugar acid uronic acid within the first day after implantation, and then days later by macrophage digestion of the fibrous residue.

Surgicel Wrapped Diced Cartilage Grafting in Rhinoplasty Indianapolis Dr Barry EppleySome controversy exists about whether to use Surgicel or the patient’s fascia to contain the diced cartilage graft for placement into the nose. The author stands by his contention based on his experience that Surgicel does not induce cartilage graft resorption. It does, in fact, create a the smooth enveloping fibrocartilaginous layer under the skin that prevents graft visibility.

This paper supports the contention that wrapped diced cartilage grafting has revolutionized the approach to dorsal augmentation in rhinoplasty. In my experience this become really significant in larger rib grafts where warping and cartilage outlien show are not uncommon.

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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