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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.

June 11th, 2017

OR Snapshots – Extended Temporal Implant

 

Temporal hollowing is commonly treated by injectable fillers and fat injections. While both of these injection methods have their merits, the assured permanent temporal augmentation method is with the use of an implant. Temporal implants are newer forms of facial implants that are specifically designed to replicate the soft feel of muscle rather than that of bone. It is the only facial implant that is designed to augment a soft tissue area.

Temporal hollowing is the result of fat atrophy, muscle wasting/thinning or a combination  of both. In modest to moderate amounts standard temporal implants do well in improving hollowing. They cover the lower half  of the temporal region from the zygomatic arch upward to the level of lateral brows.

In more severe forms of temporal hollowing the concavity extends up to the anterior temporal line at the side of the forehead. This encompasses the entire anterior temporal zone for which the standard implant is deficient in height. (vertical length) As a result an extended temporal implant has been designed that can augment the entire extent of temporal hollowing should it go all the way up to the forehead.

The extended temporal implant is placed through the same incision as the standard style. The length of the incision does not need to be extended to properly place it. Once the pocket is made the implant is inserted in a horizontal orientation and then turned 90 degrees for proper placement.

The extended temporal implant offers enhanced improvement for those so afflicted with more severe facial hollowing. Thin females, patients with medication-induced facial lipoatrophy, and extreme weight loss patients are the most common aesthetic indications for use of the extended temporal implant.

Dr. Barry Eppley

Indianapolis, Indiana

June 11th, 2017

Case Study – Two-Stage Skull Augmentation with Custom Implant

 

Background: The size of one ’s head is a personal matter based on how one sees it. Some people feel their head is too big while others feel it is too small. While there are specific ratios and numbers for head to face size, what ultimately matters is how the person themselves see it. I have seen a lot of patients with concerns about their head size and in most the cases their concerns are visibly evident.

A larger head is hard to hide but a smaller head size can be camouflaged through a variety of head wear and hairstyles. Women can camouflage a smaller head size using their hair. Fuller hairstyles give the illusion of a bigger head. But eventually some women tire of the effort of making their hair a certain way or their hair becomes damaged by continually doing so.

The small head can be augmented to some degree using custom skull implants. The thickness of the skull bone can be doubled in many cases to create an overall larger head size. How much a skull implant can do so depends on the natural stretch of the scalp, which can not be precisely determined beforehand.  My experience has shown that about 12mms of central implant thickness can be tolerated in most people. The scalp can safely stretch over an implant and allow for a comfortable incisional closure. More implant thickness or volume requires a first-stage scalp expansion procedure.

Case Study: This 30 year-old female ha done been bothered by the small size of head. She wanted a head that was taller and face her better balance to her face. A 3D CT scan showed a skull shape that  was normal but did not have a convex shape to the top. It has more of a flatter profile from front to back.

Her 3D CT scan was used to make a custom skull implant that added a lot of height (1t5mms) as well as broader coverage over the rest of her skull. Given its desired size it was felt that her scalp would not stretch enough to be placed without a first stage expansion.

A scalp tissue expander was placed in a first operation with a remote port placed under the skin above the right ear. She was able to place 110cc of saline volume into the expander over the next six weeks.

During a second operation the custom skull implant was placed  through a minor extended scalp incision that was limited to just across the top of her head. The scalp closure was tight but closed comfortable with metal clips.

Her results at just two weeks after surgery showed a nice increase in her head height and a well healing scalp incision.

Larger or more extreme skull augmentation require scalp expansion first. At the time of the implant placement the capsule from the expander misty bone removed from the bone as well as from the edges of the expander capsule. This will allow the scalp to fully maximize its expansion through these scar releases.

Highlights:

  1. The size of any skull implant depends on the stretch of the soft tissue to accommodate it.
  2. Larger skull augmentations require a first-stage skull expansion to ensure that there will be enough scalp to close over it.
  3. The timing between the placement of a scalp tissue expander and the secondary placement of a skull  implant is usually around six weeks.

Dr. Barry Eppley

Indianapolis, Indiana

June 11th, 2017

The Anterior Septal Angle in Rhinoplasty

 

The open approach is the most commonly used technique in contemporary rhinoplasty. Whether it is a primary nose or a secondary revision, the open approach provides wide access and visualization of all nasal structures. But once inside how does the plastic surgeon decide to proceed?.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘The Importance of the Anterior Septal Angle in the Open Dorsal Approach in Rhinoplasty’. In this review paper the authors discuss the importance of the anterior septal angle as it contributes to nasal tip support and length as well as internal nasal valve anatomy and airway function. There are many important nasal maneuvers that can be from the anterior septal angle from spreader grafts, septal angle reduction, septoplasty and cartilage harvest to caudal septal resection and the placement of columellar strut grafts.

The importance of the anterior septal angle is described using the four gateways. The dorsal gateway allows for dorsal aesthetic line creation/restoration, septal reduction and spreader grafts and correction of the deviated noise with spreader grafts. The posterior gateway allows for airway obstruction improvement by septal correction back to the vomer as well as cartilage harvest with emphasis on maintaining 10 to 15mms of L-shaped septal construct. The nasal tip gateway looks at the role that the anterior septal angle plays in tip support, specifically the use of septal extension grafts to control tip projection and shape. Anterior septal angle reduction can also be done in the tension nose to help widen the external and internal valves. The caudal gateway allows for the placement of columellar strut grafts and depressor septa muscle transection.

What has become apparent after decades of performing open rhinoplasty surgery is that the identification of the anterior septal angle is the first step after exposure or degloving of the nose is done. From this anatomic point all structural changes can be initiated.

Dr. Barry Eppley

Indianapolis, Indiana

June 10th, 2017

Tear Trough Fat Grafting During Lower Blepharoplasty

 

Lower eyelid aging creates a number of well known aesthetic deformities. From excessive skin, herniated orbital fat, malar-palpebral grooves to tear troughs, the anatomic changes to the lower eyelid have been well chronicled. Tear troughs and the correction of this nasojugal groove have been treated by both injected fillers and fat as well as different surgical blepharoplasty techniques.

The surgical correction of the tear trough deformity has included orbital fat transposition, release of the orbitomalar ligament and tear trough implants….or some combination of them. While these can be done using an external skin or an internal conjunctival approach, the most consistently effective is the external approach or the skin-muscle flap technique. Its enhanced visibility allows for the redistribution/rearrangement of local tissues to a reproducible autologous rejuvenation effect.

In the June 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty’. In this paper the authors report their results of 32 lower blepharoplasty patients who had their tear trough deformities treated by the addition of micro free fat grafts with an average followup of one year. In their technique they minced any removed orbital fat pockets into small 2mm to 3mm grafts. (micro free fat grafts) These are then placed into a space created by the release of the orbitomalar ligament. Their results showed consistent good improvement of the tear trough deformity. No patients developed infection or lid deformities. One reoperation due to sclera show was needed (3%) while temporary conjunctival swelling occurred in just over 10%.

Traditional lower blepharoplasty techniques in the face of tear trough can often leave them looking worse by exacerbating the appearance of the preoperative hollows or dark circles. The concept of not merely discarding herniated orbital and reusing it either through pedicled flap transposition or free fat grafts is a logical one. What is appealing about free fat grafts is that they are more versatile than a peddled flap. They can be placed more consistently, in greater volumes and with more precise placement. Such solid small fat grafts have been known to survive for as long as thirty years ago with reports of the use of ‘pearl fat grafts’ in the face.

Free fat grafting of the tear trough during lower blepharoplasty can be done with fat harvested from anywhere not just the use of orbital fat. Small grafts taken from the buccal fat pad is a good example of a regional fat donor source. Whether its survival is as good as orbital fat can not be determined but there is no reason go think that it would be less.

Dr. Barry Eppley

Indianapolis, Indiana

June 7th, 2017

Case Study – Female Teenage Cleft Rhinoplasty

 

Background: A cleft through the upper lip always affects more than just the lip. As the cleft cuts through the nasal sill on its way back through the alveolus and palate, the nasal structures above it are altered in very predictable ways. The internal septum deviates towards cleft side, the contralateral inferior turbinate enlarges, the ipsilateral lower alar cartilage slumps, the nostril base widens and retracts inward, and the columella and tip of the nose tilts to the cleft side. Even high up above the cleft the nasal bone on the cleft side  is affected, being wider and lower.

A cleft rhinoplasty to be successful must address many of these structural disturbances. Supporting the tip of the nose and nostrils against overlying skin which has historically been distorted, and even deficient, requires the creation of cartilaginous structures to push out on the skin and resists its memory. Cartilage grafting is paramount and the best grafts as possible need to be obtained. A septum that has never been operated on is ideal but this is not always the case. When in doubt a small rib graft is always the go to graft in cleft rhinoplasty.

Cartilage grafting in the nose has a variety of well known graft locations and names. But in the end the tripod construct is what is needed ensuring that a columellar strut, spreader/dorsal grafts and batten or alar rim grafts are needed to help create a better shaped and projecting nasal tip. Even with the creation of the best underlying cartilage framnework, cleft rhinoplasty results can be very humbling.

Case Study: This 15 year-old female was born with a right complete cleft lip and palate deformity. She has been through primary lip and palate repairs as an jnfant  as well as secondary alveolar bone grafting and tip rhinoplasty as a young child. As a teenager she sought a more definitive nose reshaping procedure.

Under general anesthesia and through an open rhinoplasty approach, the septal deviation and cartilages were obtained coming down through the anterior septal angle.  The contralateral inferior turbinate was also reduced. Spreader, columellar strut and cleft- sided batten cartilage grafts were used. The right nasal base was also moved down and inward.

Her longer-term results shows definite improvement in the shape of the nasal tip and nostrils. But her thicker nasal skin precludes as much refinement as one would have hoped.

Highlights:

  1. A more formal cleft rhinoplasty can be done as easily as the mid-teens.
  2. Most cleft rhinoplasties need cartilage grafts and the septum is the best source of strong straights grafts if possible.
  1. Rebuilding/add support to the cleft nostril is the cornerstone to rhinoplasty in most cleft patients.

Dr. Barry Eppley

Indianapolis, Indiana

June 7th, 2017

OR Snapshots – Submental Chin Reduction Incision

 

Chin reduction is a far more challenging operation in many ways than chin augmentation. Unlike chin augmentation, which rarely has to consider the overlying soft tissue because it stretches it out, this is a major consideration when making the chin smaller.  While the chin bone can be reduced in all of its dimensions (height, width and projection), the overlying chin soft tissue pad and the tissues on the underside of the chin do not magically shrink down when its bone support is lessened.

In cases of minor chin bone reshaping an intraoral approach may be effective and not cause adverse soft tissue effects. But the risk of creating a witch’s chin and submental soft tissue redundancies becomes very real as the chin bone reduction becomes greater and more of its soft tissue attachments are released.

The soft tissue issues are not ameliorated by an intraoral sliding genioplasty technique for horizontal chin excess. While cutting and sliding the chin bone back does keep inferior border soft tissues attached and reduces the risk of a witch’s chin deformity, it causes submental fullness as the attached soft tissues get pushed back.

The role of the submental chin reduction technique is that it manages both bone reduction/reshaping and removes/tightens the overlying soft tissues. It accomplishes both tissue reductions by an external skin incision in the anterior submental region. While the resultant scar is always a nervous trade-off, good placement and limited lengths make for a favorable scar outcome.

The key to the submental scar is its initial placement on the back edge of the inferior border and in a curved fashion. Its length should never exceed vertical lines drawn down from the mouth corners even during closure if working out dog ears are necessary. The incision should stay within the confines of the mouth width. The other key is when removing soft tissue excess, int is actually worked out of the neck not the soft tissue chin pad. This prevents the resultant scar from ending up on the front edge of the soft tissue chin pad where it could become more visible.

Dr. Barry Eppley

Indianapolis, Indiana

June 6th, 2017

Case Study – Abdominal and Waistline Power-Assisted Liposuction

 

Background: Fat removal by liposuction remains the most common body contouring surgery, particularly if one looks at body surface areas treated. Having been around for over 35 years liposuction has undergone many technologic advancements. The vast majority of these improvements have been in the equipment needed to perform it from cannula design to the devices used to free and remove the fat.

While liposuction has been historically powered by ‘elbow grease’, manually moving the cannula back and forth, this is the least efficient and most laborious technique for performing it. Many energy-based devices have been developed to make the fat particulation part of the process more efficient and effective. Using energies of focused light (laser), ultrasonic waves and high flow water, various manufacturers have put forth their machines for commercial use. Understandably all claim their superiority for improved liposuction results.

One low tech but popular liposuction technology is that of a power-assisted method. What this means, and is unique amongst all liposuction technologies, is that the tip of the cannula moves back and forth thousands of time a minute using ana electric motor. This is a miniature form of manually moving the cannula back and forth but being done by a machine. This creates much more action at the end of the cannula that could ever be done manually and spares fatigue on the operator as well.

Case Study: This 39 year-old female wanted to reduce some fullness across her abdomen and around her waistline into her back. (flanks) She was at a good weight but was un able to shed this fat layer.

Under general anesthesia and using a tumescent infiltration fluid, a 4mm cannula was used on a power-assisted device. A total of 2,150cc of fat aspirate was obtained from the entire abdomen and waistline. At six weeks after surgery she had a complete recovery and  the treated areas showed substantial contour improvement.

Power-asssisted liposuction is one of the many contemporary liposuction technologies. It offers more efficient cannular fat extraction with less surgeon fatigue than traditional liposuction. These features are attractive to patients as well as less surgeon fatigue means greater sustained intraoperative efforts…which is often the key to good liposuction results regardless of the technology used.

Highlights:

  1. Liposuction remains the single best method for fat removal in the trunk.
  2. Many different technologies exist for performing liposuction, the ideal method remains to be determined.
  1. Power-assisted liposuction (PAL) is an effective liposuction method that uses an oscillating tip to reduce operator fatigue and improve efficiency.

Dr. Barry Eppley

Indianapolis, Indiana

June 5th, 2017

Male Custom Brow Bone Implants

 

The shape and appearance of the forehead is highly influenced by the appearance of the brow bones. While usually taken for granted when they are normal, the brow bones or supraorbital rims serve as the roof/overhang of the eye.  A strong or weak bony overhang influences the appearance of the eye as well as that of the overall face.

The appearance of the brow bones is very gender specific. Men naturally have stronger brow bones due to greater development of the frontal sinus cavity. This results in a brow protrusion and the creation of a suprabrow break above it into the forehead. This also results in a slight backward pseudoinclination to the forehead. Conversely women had flatter brow bones, no brow bone break and a more vertical and convex forehead shape.

For the male seeking stronger brow bones, the underlying bone usually has to be augmented. Injections methods using synthetic filler and fat can be very effective to create a temporary effect  or just some slight augmentation across the brow bone proper. But a permanent and more versatile augmentation approach requires a brow bone implant.

Traditionally augmenting the brow bones requires a coronal scalp incision for access. Once widely exposed the brow bones can be built up with a variety of bone cements or implant materials. Besides the obvious lack of appeal of creating a long scar in the scalp for most men it is difficult to intraoperatively shape bone cements or even adequately place implants at the lower end of the turned down scalp flap.

A more effective brow bone augmentation approach is that of a custom brow bone implant. Using a patient’s 3D CT scan the exact dimensions and brow bone coverage of the implant can be determined BEFORE surgery. This avoids any intraoperative shaping judgments and allows a 3D shaped implant that will fit the bone precisely and create the most symmetric result.

Equally importantly a custom brow bone implant can be place WITHOUT the need for a coronal scalp incision. It can be placed using an endoscopic approach with two small scalp incisions or a single scalp incision combined with two upper eyelid incisions. Which approach is best is determined by the shape and size of the implant. Brow bone implants that some down further along the lateral orbital rims require the eyelid incisions to ensure optimal placement and fixation.

A custom brow bone implant provides a contemporary method of lower forehead augmentation that better meets the aesthetic demands of the male who usually seeks it out. Such implants are apable of being placed without creating adverse scar trade-offs.

Dr. Barry Eppley

Indianapolis, Indiana

June 4th, 2017

Case Study – Custom Jawline Defining Implant

Background: Augmenting the jawline today is more than just a chin or jaw angle implants. To change the entire jawline from angle to angle in a smooth united fashion, custom jawline implants offer aesthetic results not previously obtainable. Made from the patient’s 3D CT scan they provide a precise fit to the bone as well as smooth transitions into the surrounding bone.

Designing a custom jawline implant allows for any type of dimensions/thicknesses/shape provided that the soft tissue will permit it. What those implant dimensions should be for any specific patient depends on their goals. However, how to translate these aesthetic goals into dimensional numbers is not an exact science. The computer design process can only create what it is told, it does not know how to make anyone look exactly like they want. Such custom facial implants designs remain an art form based on the surgeon’s input at the present time.

Some patients prefer a more subtle or modest change to their jawlines. They want to provide some accents to their jawline not necessarily make it ‘big’ or have any extreme change. Creating more visible jaw angles and chin points and a smooth connection between them is their facial goal.

Case Study: This 35 year-old male wanted a jawline enhancement to create an overall more distinct jawline. He didn’t want it too big or too  noticeable. Using a 3D CT scan a custom wraparound jawline implant was designed with most changes at the chin (2mm forward and 3mms vertical elongation) and the jaw angles. (4mms vertical elongation and 4mms jaw angle width)

Under general anesthesia and through two intraoral incisions and one submental incision, the custom implant was inserted in a subperiosteal plane as a one-piece unit. It was secured with three small screws at the chin and jaw angles.

He had a full recovery at six weeks after surgery. When seen three years later he had a subtle but distinct change to his jawline as would have been expected given the modest size of the implant’s dimensions. A smooth connection existed between the front and back end of the jaw creating a smooth linear jawline effect.

Highlights:

  1. A custom jawline implant augments the entire jawline from angle to angle, hence the term ‘wraparound’ to describe it.
  2. Selecting the dimensions of the implant during its preoperative design is an art form for which there is not exact science.
  3. The implant’s dimensions can be modest to only create a jawline enhancing effect.

Dr. Barry Eppley

Indianapolis, Indiana

June 4th, 2017

Case Study – Round Breast Augmentation Result

 

Background: The size of the implant chosen is the single most important decision from a patient’s perspective. More time is spent on this aspect of the surgery than other factors such as implant type, pocket location, implant profile or even the surgeon performing the procedure.

How to match implant size to the patient’s goals, however, is not an exact science. The single best method in my experience is the use of volumetric sizers which can be tried on the patient’s breast before surgery. This certainly creates  a close approximation and almost never risks choosing an implant that ends up being perceived as too small.

One of the major goals for some women is to ensure that their chosen breast implant creates a sustained full upper pole. The desire is to have a rounder looking breast augmentation whose volumes appear equal in both the upper and lower poles. While it is commonly perceived that a high profile will ensure that occurs, and it definitely helps, but the volume of the implant ultimately makes the greatest contribution for this look.

Case Study: This 44 year-old female wanted breast implants and desired a full round look that also created cleavage. She had smaller B cup breasts with firmer skin  and just a touch of mild sagging. (non-centric nipples) Her preoperative sizing showed a 600cc plus implant size selection.

Under general anesthesia and through an inframammary incisional approach, a partial submuscular pocket was created and sizers inserted. That were inflated up to 650cc at which point the pocket was very tight. The sizers were removed and replaced with high profile 650cc silicone implants inserted with a no-touch funnel technique.

Her six week after surgery result showed a round breast augmentation result with equal distribution of volume both above and below the nipple.

While the projection or profile of a breast implant has value it remains secondary to implant volume. Filling the created implant pocket fully is the most assured way to have a rounder breast augmentation result.

Highlights:

  1. The selection of breast implant size is based own numerous factors but the most important one is what the patient’s goals are.
  2. Creating persistent upper pole fullness is related to both implants size and implant position.
  3. Filling up the implant pocket fully will create a rounder and higher breast look.

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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