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Plastic Surgery
Dr. Barry Eppley

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

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

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

October 22nd, 2016

Choosing Jaw Angle Implant Styles

 

The development of new jaw angle implant styles has finally allowed augmentation of the back part of the jaw to get caught up with that of the chin. The jaw angles have been overlooked for a long time as implant styles and sizes of the chin have progressed. With the chin and jaw angle implant styles that are now available the entire jawline can be augmented in the properly selected patient.

widening-jaw-angle-implants-design-dr-barry-eppley-indianapolisWith newer jaw angle implant styles, it is important that the indications for their use are clear. Traditionally jaw angle implants really only provided width to the mandibular ramus. They were designed to sit on the bone on its natural shape, thus increasing its lateral projection. Making the jaw wider is an effective aesthetic strategy provided the mandibular plane angle is not too high. If the jaw angles are within 2 cms or lesss from the earlobe they would be considered high jaw angles. A high jaw angle that is made wider can potentially make the face look too full or chunky and not create a more defined and stronger jawline.

widening-jaw-angle-imlpants-3d-ct-scan-dr-barry-eppley-indianapoliswidening-jaw-angle-implants-in-high-jaw-angles-dr-barry-eppley-indianapolisThis is a 3D CT example of this exact mismatched jaw angle implant problem. This patient has very high jaw angles and a steep mandibular plane angle. While these widening jaw angle implants are reasonably well placed over the rami the patient developed an undesired facial appearance as the enhanced jaw angles remained too high.

vertical-lengthening-jaw-angle-implants-design-dr-barry-eppley-indianapolisNewer styles of jaw angles help vertically lengthen the lower border of the mandibular ramus to treat the high jaw angle patient. This is a very unique facial implant style as a portion of the implant sits off of the bone to create its effect. As much as one third of the implant does not sit on the bone. In lowering the jaw angle it becomes more visually defined and the lower face appears more filled out in the front view. Vertical lengthening of the jaw angle is the most assured way to create a more visible back part of the jaw as it effectively corrects a bone ‘deficiency’. (missing part of the jaw) However one must be careful to not over lengthen the mandibular ramus as it can also make the lower face look too heavy in the patient who has a normal mandibular plane angle.

vertical-lengthening-jaw-angle-implants-dr-barry-eppley-indianapolisThis is a 3D Ct example of jaw angle implants that provide vertical lengthening. A portion of the implant design is off the bone to both lower and make more prominent the jaw angle shape at the back of the jaw. This is the appropriate jaw angle implant style for the high jaw angle patient.

Jaw angle implants today come in both widening and vertically lengthening styles. Each style does add some of the opposite dimension as well. Widening angle implants can add a little vertical length based on how they are positioned. Conversely the design of the vertical lengthening implant has built in width that increases the more it lowers the jaw angle

custom-jaw-angle-implant-design-dr-barry-eppley-indianapolisLike all facial implants not every standard shape and size works well for every patient. Significant jawline asymmetry, postoperative orthognathic surgery bony changes of the ramus and aesthetic dimensoonal needs beyond standard sizes are all reasons to consider custom jaw angle implant designs.

Dr. Barry Eppley

Indianapolis, Indiana

October 20th, 2016

OR Snapshots – Premaxillary Osteotomy

 

Orthognathic surgery is a well known type of bone procedures that move the upper and lower jaws to improve one’s bite (occlusion) as well as improve jaw relationships to the face. It is done on the upper and lower jaws with the mainstay procedures of a LeFort I osteotomy (upper jaw) and sagittal split ramus osteotomies. (lower jaw)

The LeFort I osteotomy moves the upper jaw and is done by a horizontal bone cut above the level of the upper tooth roots across the maxilla and nose. This allows the entire dentoalveolar unit of the maxilla to be moved horizontally forward or vertically up or down. When seen intraoperatively it is a dramatic procedure when one sees the whole upper jaw brought down to peer into the maxillary sinuses and the nose.

premaxillary-osteotomy-intraop-dr-barry-eppley-indianapolisA much less known maxillary bone procedure is that of the premaxillary osteotomy. As the name suggests it is just a part, the front part to be specific, of a LeFort I osteotomy. This is the anterior maxillary segment that contains the six front teeth from canine to canine. It is unique from the Lefort I osteotomy because it requires a vertical bone cut between the canine and premolar teeth as well as a bone cut across the palate to get the bone segment to move.

The indications for a premaxillary osteotomy are very limited. The picture in this blog is from an older patient who wanted his front upper teeth moved up and back to correct a lifelong tongue thrusting problem. This was able to be done for him because he was already missing his first premolar tooth on the right side and had a decayed second premolar tooth on the opposite side which could be removed. This provide a safe space to make the vertical bone cuts.

October 19th, 2016

OR Snapshots – Vertical Lengthening Genioplasty

 

Chin augmentation is traditionally thought as a choice between a chin implant and a sliding genioplasty. While seen as the two procedure choices for chin reshaping they are not really interchangeable. Besides the difference between synthetically augmenting the bone vs actually cutting and moving the bone, they can achieve different dimensional chin changes.

The one movement that a sliding or bony genioplasty can do much better than an implant is changing the vertical dimension of the chin.  While it is obvious that an implant can not shorten the chin, it historically could not lengthen it very well either. That has changed more recently with vertical lengthening chin implant styles. But the intraoral genioplasty remains an historic mainstay for increasing the vertical length of the lower face. (chin)

vertical-lengthening-genioplasty-intraop-dr-barry-eppley-indianapolisDone through an intraoral mucosal incision, the chin bone is cut well below the level of the lower tooth roots. An opening wedge is performed by dropping down the chin bone to the desired vertical distance that is needed to create the aesthetic result. In most cases the vertical gap that needs to be created is at least 7mms. Much less does not produce a very obvious vertical lengthening. The amount the vertical gap can be opened is only limited by the length of the fixation plate used and what other chin dimensions need to be changed if any.

A debatable issue with vertical chin lengthening is whether the bone ago created between the two chin segments needs to be filled in. In small gaps in the range of 5mms or less grafting of the defect is probably not needed. The body will fill it in on its own. But larger bone gaps should be grafted. I prefer to use allogeneic cadaveric bone grafts which conveniently come in wedge forms that can fit nicely as an interpositional bone graft.

October 19th, 2016

Case Study – Puffy Nipple Breast Augmentation

 

Background: Breast implants are intended to enlarge the existing breast mounds. In so doing it is often erroneously believed that other features of the breast may be similarly improved. Unfortunately this is rarely true. Conversely any other deformities or asymmetries of the breast may actually become more noticeable not less.

The most visible feature of the breast mound is the nipple-areolar complex. It has features from size (diameter), nipple projection, to its position on the breast mound. Enlarging the breast will increase the diameter of the areola. Implants will not change nipple projection unless nerve sensation is lost. Uneven horizontal nipple positions between the breast mounds will be greater as the breast gets bigger.

One unique dysmorphic feature of the nipple-areolar complex is that of the ‘puffy nipple’. This is where the entire areola puffs outward due to a collection of breast tissue beneath it. This almost always occurs as part of the spectrum of tuberous breast deformities. In its most minor form, a constricting ring around the base of the areola creates a small herniation of breast tissue through the areola ring creating a puffy nipple appearance.

Case Study: This 22 year-old female presented for breast augmentation due to her natural flat chest. What she did have were larger areolas that stood out due to their puffiness.  The areolas were soft and could easily be pushed in. Her understandable question was whether breast implants would push out the breast mound behind them and make them less puffy.

puffy-nipple-breast-augmentation-results-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, she had 400cc high profile smooth silicone breast implants placed in the dual plane position through inframammary incisions. Her immediate and early postoperative results showed no change in the appearance of her areolar protrusions.

puffy-nipple-braest-augmentation-results-oblique-view-dr-barry-eppley-indianapolispuffy-nipple-breast-augmentation-result-side-view-dr-barry-eppley-indianapolisLonger term followup failed to show any improvement in her puffy nipple concerns. This proves that the push of an implant behind an areolar protrusion does not improve it. This makes sense since anatomically a ‘hernia’ can not be reduced by pushing on the side that the prolapsed tissue emanates.

The puffy nipple must be treated by excision of breast tissue through a partial areolar incision. This can be done at the same time as the breast augmentation or deferred until the patient is convinced breast implants alone are not corrective.

Highlights:

1) Breast implants are well known to magnify the existing features of the breast.

2) The features of a nipple are not changed/improved because the underlying breast volume is enhanced.

3) The puffy nipple or the microform tuberous breast is NOT flattened because a breast implant is placed behind it.

Dr. Barry Eppley

Indianapolis, Indiana

October 17th, 2016

Case Study – Intramuscular Buttock Implants

 

Background: Buttock implants offer a method of buttock augmentation when one has inadequate fat to harvest. It has become more popular over the past decade than ever before as the patient demand for buttock augmentation has risen dramatically. But unlike fat transfer there are multiple considerations when buttock implants are considered. These include size, shape and implant location.

The biggest consideration in using buttock implants is whether they should be placed above (subfascial) or into the muscle. (intramuscular) Each implant location has its own advantages or disadvantages. The intramuscular location offers the lowest risk of long-term implant complications but the longest after surgery recovery. Its other ‘disadvantage’ is that the implant size  will be more limited. The intramuscular pocket does not allow for much bigger implants than about 350ccs of volume. This us unlike the subfascial location where much larger buttock implants can be placed.

Case Study: This 26 year-old female wanted a larger buttocks but knew she did not have enough fat to get a good result. She was aware of the concept of subfascial vs intramuscular pockets and wanted the implants placed inside the muscle. She had a flat but moderate-sized buttock shape and preoperative measurements indicated that a 300cc to 350cc implant could be placed.

intramuscular-buttock-implants-incision-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, a 7 cm. intergluteal incision was made. The intramuscular pockets were created by a muscle splitting approach. Soft solid silicone 330cc anatomic buttock implants were placed on both sides. No drains were used.

tb-buttock-implant-results-back-view-dr-barry-eppley-indianapolistb-buttock-implants-oblique-view-dr-barry-eppley-indianapolisHer two month results show a fuller and more rounded buttock shape. Her buttocks were bigger in the upper pole with increased fullness. She had a rather long recovery as it took her about a month to get back to most physical activities. She developed a partial incisional dehiscence about 3 weeks after surgery of the lower half of her incision. It was treated by topical silvadene and went out to fully heal three weeks later.

tb-buttock-implants-side-view-dr-barry-eppley-indianapolisFor those patients considering intramuscular buttock implants it is important to realize that the recovery period will be significant. It is a muscular injury in an area that will need to be sat on as well as important for many other bodily movements as well.

Highlights:

1) Buttock implants offer a reliable and permanent method of buttock augmentation

2) The intramuscular placement of buttock implants offers the least complications long-term but has a significant surgical recovery.

3) Intramuscular buttock implants have size restrictions and are only indicated in patients that are not eligible for a fat transfer buttock augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

October 16th, 2016

Case Study – Female Custom Jawline Implant

 

Background: While jawline augmentation is most commonly associated with men, it is gaining aesthetic significance in women as well. A strong jawline is historically associated with increased masculinity. Women are more associated with softer and more recessed chin positions and jawline shapes. But the contemporary female jawline is now desired to have a more definitive jawline with increased angularity particularly at the posterior jaw angle area.

The one jawline dimension that is the hardest to change in both men and women is that of its vertical dimension. Short of orthognathic surgery to correct a deep bite, vertical augmentation with implants is needed to lengthen the lower face. But no standard chin or jaw angle implant provides any substantial vertical elongation. And lengthening the entire jawline as a single unified structure by bony movement requires the chin wing osteotomy with its own set of aesthetic issues.

female-custom-jawline-implant-design-dr-barry-eppley-indianapolisCase Study: This 26 year-old female presented with a history of injectable fillers to her chin to correct a significant chin deficiency. Despite multiple ccs of filler she still had a horizontal chin deficiency. Equally pertinently is that her lower jaw was vertically short compared to the upper two-thirds of her face. A custom jawline implant was designed to both vertically lengthen her entire jawline from angle to chin as well as provide horizontal chin augmentation.

female-custom-jawline-implant-intraoperative-insertion-dr-barry-eppley-indianapolisUnder general anesthesia the custom jawline implant was inserted through an intraoral approach. Three intraoral mucosal incisions were used including an anterior one below the front teeth and two posterior ones behind the second molars. It was inserted as a single piece passing it under the mental nerves from the chin area back to the jaw angles.

female-custom-jawline-implant-fronjt-view-ddr-barry-eppley-indianapolisfemale-custom-jawline-implant-oblique-view-dr-barry-eppley-indianapolisHer immediate after surgery results showed a substantial improvement in the fullness of her lower face. Her chin has better projection and her jawline back to the angles was more visible and defined.

female-custom-jawline-implant-result-side-view-dr-barry-eppley-indianapolisCustom jawline implants in females can be done just as it is in men. The difference is that they are often smaller in overall size with less dimensional augmentation. Creating a sharper and more defined jawline, not necessarily a substantially bigger size, is their usual focus. The exception is in the vertically short jawline where the lower face is disproportionately smaller than the upper two-thirds. In these cases vertical jawline lengthening needs to be done and pull down and out the lower third of the face.

Highlights:

1) Custom jawline augmentation for women can be done as successfully as that in men.

2) For vertical lengthening of the jawline in women only a custom jawline implant will suffice.

3) Most women get smaller custom jawline implants which may allow for a complete intraoral placement approach.

Dr. Barry Eppley

Indianapolis, Indiana

October 14th, 2016

Earlobe Attachment Surgery

 

One of the features of an earlobe is in how they attach to the face. In some patients the earlobe curves upwards and attaches to the face in an inverted V shape. They are often referred to as unattached earlobes. In other patients the earlobe joins the face directly without any break in he attachment. This is often referred to as an attached earlobe. While earlobes are often described as either attached or unattached (free), the reality is that there are variations that commonly occur between these types.

Some people desire to change the way their earlobe attaches to the face. It is fairly easy surgically to take the unattached earlobe and make it attached. This is done by excising skin from the medial side of the earlobe as well as a similar strip of skin on the opposing facial side. the two are then sutured together. This union heals very well and does so in a virtually scarless manner.left-earlobe-attachment-surgery-result-dr-barry-eppley-indianapolis

right-earlobe-attachment-surgery-result-dr-barry-eppley-indianapolisConverting an attached earlobe to an unattached one poses a slightly different challenge. The skin attachment is released and the medial side of the earlobe is sewn up along its open margin. This changes the earlobe into a more rounded lower shape. But the facial side of the wound opening must also be closed and is done so in a linear fashion. This leaves behind a vertical scar in an unnatural location. Fortunately the wound closure heals fairly well in this location and can be partially obscured by the earlobe itself.

Changing the attachment of the earlobe to the face can be done under local anesthesia with negligible swelling and no real recovery.

Dr. Barry Eppley

Indianapolis, Indiana

October 12th, 2016

Earlobe Reduction Techiques

 

Lengthening of the earlobe as one ages is both an old adage as well as a reality. Being the only soft tissue structure of the ear that is not supported by cartilage, it is prone to becoming stretched. Being on the southside of the ear, gravity is also not in its favor. This elongation effect can also become  magnified by the wearing of heavy ear rings/jewelry Big earlobes can affect both women and men and can be a source of both ear disproportion and embarrassment.

Earlobe reduction surgery is an uncomplicated procedure that can be performed under local anesthesia even in an office setting. Due to its superb blood supply, good healing always occurs and the risk of adverse scarring is very low even in patients with darker pigments.

left-earlobe-reduction-wedge-excision-results-dr-barry-eppley-indianapolisThere are four different methods of earlobe reduction of which two methods dominate. The traditional method involves the removal of a pie-shaped wedge of tissue right through the middle of the ear. In bringing the now split earlobe back together it is both vertically and horizontally shortened. This leaves a fine line scar right down the middle of the earlobe. But contrary to what one might expect, this scar usually heals quite well and is barely detectable.

left-helical-rim-earlobe-reduction-result-dr-barry-eppley-indianapolisThe second method is known as a helical rim earlobe reduction method. The earlobe is reduced in size by removing a curved ellipse of tissue across the base of the earlobe. The advantage of this technique is that the fine line scar is more hidden on the bottom of the earlobe. Because of its curved excisional design it also reduces the length and width of the earlobe.

helical-rim-earlobe-reduction-result-left-side-dr-barry-eppley-indianapolisOne interesting aspect of any earlobe reduction technique is in how the earlobe attaches to the face. Such earlobe attachments can be direct or have an inverted V form of attachment. The relevance of that is how it affects the earlobe reduction. In the earlobe that has a break (inverted V), this attachment is not disturbed. But in earlobes with a direct attachment vertical earlobe shortening will create the need for a linear closure of the previous attachment. This creates a small vertical scar below the new level of the earlobe.

Dr. Barry Eppley

Indianapolis, Indiana

October 12th, 2016

Asian Buttock Implants

 

Buttock augmentation today has taken on a near significance as to that of breast augmentation. It is the second most augmented body part next to that of the breasts. Debates can be had as to why this is so but it is a phenomenon that crosses many ethnic and cultural groups.

What constitutes buttock beauty is more than that of just size. The curve of the buttocks as transitions into the back and hips are features that may be as aesthetically valuable as pure size alone. A pleasing curvature from the back into the upper buttocks, increased hip volume and a rounder plumper shape are important aesthetic goals as well.

Currently injectable fat grafting offers the best method to try and achieve all of these buttock augmentation goals as the volume placement can cover a broader surface area. But not everyone is a good candidate for fat grafting due to inadequate tissue or failure of sufficient fat to survive. This leaves buttocks implants as the only other buttock augmentation option.

buttock-implants-indianapolis-dr-barry-eppleyIn the September 2016 issue of the Annals of Plastic Surgery, an article on buttock augmentation was published entitled Buttock Reshaping With Intramuscular Gluteal Augmentation in an Asian Ethnic Group: A Six-Year Experience With 130 Patients’. In this paper the authors performed an intramuscular implant technique using the well known XYZ method for pocket creation and implant positioning. The buttock implants used were of the oval-shaped smooth-surfaced silicone type. Most of the patients also had  lipsouction performed as well.The aesthetic results were determined using serial photography and by the patient’s own assessment on a 5-score scale.

The mean rating for patient satisfaction with the procedure was 4.6 of 5. (92%) The ratings of two independent plastic surgeons showed a mean score of 4.2 of 5. (84%) The authors conclude that intramuscular gluteal augmentation technique using solid silicone implants resulted in high patient satisfaction and good cosmetic reshaping of the buttocks.

asian-buttock-implants-result-back-view-dr-barry-eppley-indianapolisasian-buttock-implants-result-side-view-dr-barry-eppley-indianapolisThe unique aspect of this paper is that it describes the use of buttock implants in Asian women. What is unique in buttock augmentation about Asian women is that they often do not have enough fat to harvest for a BBL procedure and implants would be their only treatment option. Fortunately their size goals are usually more modest and a rounder shape is more important than a significant increase in size. This is the type of effect that is achievable with buttock implants and explains the high satisfaction rate for the procedure in this patient population.

Dr. Barry Eppley

Indianapolis, Indiana

October 10th, 2016

Case Study – Buttock Reconstruction with Dermal-Fat Grafts

 

Background: Fat grafting to the buttocks is most commonly done for aesthetic reasons as in the well known Brazilian Butt Lift (BBL) procedure. Large numbers of patients treated around the world has shown that it can be very successful with relatively high amounts of fat retention in many patients. Less is well known, however, about fat grafting into the deformed or scarred buttocks for reconstructive purposes. (although a lot is known about fat grafting in breast reconstruction)

The most common use for fat grafting in buttock reconstruction is in the management of illicit silicone oil injections. While the injected silicone material can never really be removed the purpose of the fat injections to break up the scar contractures and introduce healthier tissue amongst them. Its effects are not really for volume augmentation per se. But injectable fat grafting is still effective for these purposes.

The rare condition of cojoined twins (one in 200,000 births) is a congenital condition that may require secondary buttock reconstruction. One type of cojoined twins is pygopagus (iliopagus) where they are joined back to back at the buttocks. This is reported to occur in about 20% of cojoined twin cases. Their separation ends up creating buttock scars and contour deformities as would be expected that awaits secondary reconstruction.

Case Study: This 26 year-old female presented with buttock scar contractures from having been separated at birth from her twin. Both buttocks had significant indentations, wide scarring and very visible suture track marks.

buttock-reconstruction-with-dermal-fat-graft-dr-barry-eppley-indianapolisbuttock-reconstruction-with-dermal-fat-grafts-back-view-dr-barry-eppley-indianapolisUnder general anesthesia and in the prone position, all of her buttock scars including the track marks were excised. The deeper tissues were released and skin flaps raised. A large dermal-fat graft was harvested from the lower abdomen. The graft was de-epithelized and placed in a dermal up side position into both buttock defects and sutured into place. The incisions were closed in more narrow and linear line closures.

buttock-reconstruction-with-dermal-fat-grafts-result-bvack-view-dr-barry-eppley-indianapolisbuttock-reconstruction-with-dermal-fat-grafts-result-left-side-view-dr-barry-eppley-indianapolisHer four month after surgery results show that the fat grafts had been maintained as the buttock contours obtained in surgery persisted. The scars remained hyperpigmented as would be predicted give her ethnicity.  Secondary scar recision can be done later if desired.

While injectable fat grafting is most commonly used in the buttocks, scar contractures present different challenges. Wide scars and severe indentations may be better served by excision and deep scar release. This creates an open defect into which the need for traditional dermal-fat grafting must be used to create volumetric fill. These larger dermal-fat grafts take well in my experience.

Highlights:

1) Buttock contour deformities due to scarring can be effectively treated by fat grafting.

2) Injectable fat grafting to a deformed buttocks may require more than one injection session to optimize the buttock shape.

3) Dermal-fat grafting to the buttocks allows for scar revision and release at the same time but also requires a donor site harvest and scar.

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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