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Dr. Barry Eppley

Explore the worlds of cosmetic
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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.

November 5th, 2015

Earlobe Reduction and Facelift Surgery

 

A facelift is a very well known facial rejuvenation procedure that has its primary effects on the addressing loose skin and tissues in the neck and jawline. While there are a large number of iterations and varieties of described facelift techniques, they all require incisions around the ears to create their desired effects. While much focus on facelift surgery is on such manipulations as the SMAS or fat grafting, the management of the incision locations and their effect on the ear and the hairine are actually of equal importance.

Facelift Vectors Dr Barry Eppley IndianapolisWhile a debate can be made for whether the facelift incision goes into the ear (retrotragal) or in front of the ear (preauricular), it always goes around the earlobe on its way to behind the ear. One of the key elements of this incision pattern is to not have traction or a downward pulling effect on the earlobe with the raised skin flap to avoid postoperative earlobe distortion. (the so called pixie earlobe deformity)

But another  earlobe consideration before and during a facelift is its size. (vertical length) While facelift surgery will always create a temporary earlobe enlargement due to swelling, a good cradling technique of the skin flap underneath the earlobe from the facelift can also make it bigger. This can be an even be a more exaggerated effect when the earlobe is too large/long before surgery.

Elongated earlobes in women are common as they age due to the weight of ear rings and gravity. While the typical vertical ear length is around 60 to 65mm in women, the elongation of ear size comes from the earlobe with aging. When the earlobe makes up more than 1/3 of total ear size, it is judged as too long.

Faceliftv Earlobe Reduction marking Dr Barry Eppley IndianapolisFacelift Earlobe Reduction result Dr Barry Eppley IndianapolisEarlobe reduction can be performed at the same time as a facelift. The best technique to do so is a helical rim reduction after the completion of a facelift. This allows maximal earlobe reduction to be done without comprising vascular perfusion to the earlobe or disrupting the incisional closure of the facelift incisions.

Earlobe reduction is a simple procedure that adds little extra time to facelift surgery and can help improve its aesthetic results. It requires preoperative awareness of ear size and the awareness of the impact of a facelift surgery on their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

November 5th, 2015

Maximal Buried Penis Repair Technique

 

buried penisThe buried penis problem is adult men is almost seen with pubic and abdominal tissue redundancies. Obesity to some degree is a frequent accompaniment to the hidden penis. But even in weight loss patients the tissue redundancies are not completely solved and only the subcutaneous fat layer gets thinner. The skin overhang and loss of penile show remains.

The buried penis poses multiple problems which are completely predictable. The urinary stream is obstructed and this poses obvious hygiene issues. This is compounded by the moist skin folds underneath the tissue excesses.  This creates the potential for irreversible skin change on the shaft such as lichen planus and scarring. Sexual activity is usually limited or impossible to perform due to both physical limitations and embarrassment.

In the November 2015 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Limited Panniculectomy for Adult Buried Penis Repair’. In this paper, the authors describe a procedure which includes a combination of a mons panniculectomy, fixation of adjacent skin to the base of the penis, removing abnormal penile skin at its base and skin grafting the residual penile shaft defect.

While an overhanging abdominal pannus creates its own contribution to the buried penis, a large mons mound has a more direct influence on it in some men. This is a tissue excess that is situated between the visible waistline superiorly and the penis inferiorly and drapes over it. This leaves only an inverted hole or funnel where the penis is ‘hidden’. While mons liposuction in some male patients may be adequate to create increased penile exposure, a large mons mound with excess skin requires skin removal as well. This is where the mons panniculectomy is useful. This directly removes a large of tissue just above the base of the penis but also allows access to secure the skin around the penis toi be sutured down to the pubic symphysis.

Fortunately addressing poor penile shaft skin is not often needed. But if the penile skin is of poor quality due to chronic irritation or is restricting the penis from coming forward, it need to be released and removed. Skin grafting can be done directly to Dartos fascia which is best to allow the skin graft to stretch during erection. Split-thickness skin grafting is best to allow for quick and complete take in most cases.

The mons panniculectomy and penile release with skin grafting is the most aggressive approach to the treatment of the adult buried penis repair. But in some men with a large pubic mound this may be the only effective approach.

Dr. Barry Eppley

Indianapolis, Indiana

November 4th, 2015

Case Study – Rhinoplasty for the Aging Overprojected Nose

 

nasal tip cartilagesBackground: The shape of the nasal tip is primarily affected by its anatomic composition. The size, thickness and length of the lower alar cartilages create the major shape of the lower third of the nose. Combined with the thickness of the nasal skin over these cartilages the shape of the nasal tip is defined.

The nose is a fairly stable structure throughout one’s life being located in the very center of the face. Supported by bone and cartilage, the composition of the nose is more hard tissue than soft tissue. The rest of the face around the nose undergoes well known aging changes but the nose is less affected. But that does not mean that it does not age at all.

Numerous people feel that their nose has become ‘bigger’ as they have gotten older. Just as teeth can age as known by the historic phrase ‘long in the tooth’ (due to soft tissue gingival recession), the nose can have its own unique set of age-related changes.

Case Study: This 60 year old female has always felt she had a long nose and had wanted a rhinoplasty for some time. As she had gotten older she felt her nose has gotten longer and wider.

Overprojecting Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia she has an open rhinoplasty. Her lower alar cartilages and caudal septum were shortened and the tip reshaped. She had no work done on the upper half of her nose to change her dorsal height and nasal bony width.

Overprojecting Nose Rhinoplasty result side view Dr Barry Eppley IndianapolisOverprojecting Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisHer one year results show descreased nasal tip length and slight upward nasal tip rotation.  Her nasal tip was also less wide.

As people age the nose does actually become a bit longer and and the nasal tip may develop more of a droop. This is a well known phenomenon due to weakening of the nasal tip ligaments where the cartilaginous tip complex can ‘slide’ slightly off of the upper lateral cartilages and bone. This can take a nose tip that is already long and heavy to become more so. Rhinoplasty surgery can have a nose aging reversal effect with tip deprojection surgery.

Highlights:

1) The overprojecting nose that is accentuated by aging is one where the lower alar cartilages are long, creating a nasal tip that sticks out too far and may droop down.

2) Rhinoplasty for the overprojecting aging nose shortens the lower alar cartilages and brings the tip back and up. (deprojection)

3) Surgical manipulation of the lower alar cartilages also allows the width of the nasal tip to be narrowed as well.

Dr. Barry Eppley

Indianapolis, Indiana

November 3rd, 2015

Technical Strategies – Minimal Incision Temporal Reduction Technique

 

Reduction of an undesired temporal convexity is becoming increasingly requested as it becomes aware that a procedure exists to do it. For a head that is too wide or convex above the ears, a technique has been developed to help narrow it. While such a temporal convexity is often perceived as being due to bone, the anatomy of the area indicates that the posterior belly of the temporalis muscle makes the greater contribution.

Resection of the posterior temporalis muscle can make a dramatic change in the shape of the side of the head. It can alter a convexity to a straight line as the thickness of the muscle is greater than one would think. In men the posterior belly of the temporalis muscle can be 7mm or more in thickness. Reduction of both sides of the head can thus result in a total width change of the head of up to 1.5 cms. Interestingly loss of the posterior temporalis muscle does not result in any loss of mouth opening.

Limited Incision Posterior Temporal Reduction technique Dr Barry Eppley IndianapolisLimited Incision POsterior Temporal Reduction technique 2 Dr Barry Eppley IndianapolisThe traditional method of posterior temporal reduction is done through a vertical scalp incision above the ears. Initially I made a 4.5 cm incisional length to remove the muscle. Having done the procedure many times I have been able to shorten the length of the incision down to 3 cms. This allows a subfascial approach to the head width in this area, reducing it by taking it out as a single piece of muscle.

left posterior temporal reduction result intraop dr barry eppley indianapolisTo demonstrate how effective posterior temporal reduction can be, here is an intraoperative view of the left side having been compared to the right side where the muscle still remains.

Dr. Barry Eppley

Indianapolis, Indiana

November 2nd, 2015

Case Study – Chin Cleft Creation Surgery

 

Background: One of the very unique aesthetic features of the chin are dimples and clefts. While often perceived as being similar, they are not. Chin dimples are central circular indentations in the central mound of the chin pad. A chin cleft is a vertical groove located more along the inferior chin pad and crosses along the edge of the bone. Both can have variable depths and degrees of prominence. Both involve soft tissue defects that go through the mentalis muscle beneath it.

male chin cleftfemale chin cleftChin clefts are well recognized and famous men and women are known to have them. Chin clefts are far more common in men although they can occur in women as well. Often perceived as being a masculine trait, the vertical chin cleft creates a very recognizeable feature of the lower face.

These variously shaped indentations in the chin are both revered and despised. Some people like them who do not have them while others who have them do not like them. There are surgeries of variable effectiveness that can both create and reduce their appearance. Chin cleft creation surgery does exist and the most well known celebrity who is known to have it done in recent times is the singer and entertainer Michael Jackson.

Case Study: This 45 year old male desired a vertical chin cleft to be placed down the central lower end of his chin. He was aware that there would be a trade-off of a vertical scar in the center of it.

Chin Cleft Creation Surgery intraop Dr Barry Eppley IndianapolisUnder local anesthesia  a chin cleft creation surgery was done. A near full thickness wedge of soft tissue (skin, fat, muscle) was removed along the length of the desired chin cleft. Deep sutures were placed to sew down the skin edges to the periosteum of the bone. This created an initial skin edge puckering effect which will go away as it heals.

Chin Cleft Creation Surgery result front view Dr Barry Eppley IndianapolisHis 6 month results show a visible vertical chin cleft of medium depth. The skin scar was virtually undetectable in the center of the chin cleft

Chin cleft creation surgery (chin cleftoplasty) is a simple procedure that can be done under local anesthesia in the office as an isolated operation. It can also be safely combined with all other forms of chin reshaping surgeries.

Highlights:

1) A chin cleft is a vertical midline indentation in the lower chin that has variable depths and lengths.

2) The best method for chin cleft creation surgery is an external approach removing a full thickness wedge of tissue.

3) External chin cleft creation surgery usually results in an acceptable scar that can be hard to detect in the depth of the cleft.

Dr. Barry Eppley

Indianapolis, Indiana

October 29th, 2015

Sientra Suspends Selling Breast Implants

 

Breast implants in the United States are commerically available from three manufacturers, Allergan, Mentor and Sientra. The newest provider is that of Sientra which has been selling their breast implants only since 2012. Although its corporate headquarters are in California, Sientra has its implants manufactured in Brazil. This manufacturing facility produces Silimed breast implants which are used around the world and are the most common type of breast implant in many countries.

Sientra Breast Implants Indianapolis Dr Barry EppleyIn just three years Sientra has introduced  many new breast implant styles and innovations. Because they were the first to have a highly cohesive and forms stable siliocone gel, they inirtially were known as the ‘gummy bear’ breast implant. They have grown to over three basic smooth round silicone implant styles (105, 106 and the recent 107) as well as textured anatomic implant as well. They have become increasingly popular amongst board-certified plastic surgeon as they will only sell their breast implants to those so trained.

Last month Sientra voluntarily put a moratorium on their products because of concerns about issues at the manufacturing plant in Brazil. This was not an FDA action or requirement and there is no known safety issue for patients. The origin of these concerns stem from regulators in Europe where they suspended sales of Silimed implants although there has not been any identifiable patient safety issue. In a prospective action, Sientra stepped forward and voluntarily suspended U.S. sales until the concerns are clarified and any problems identified solved. This has left plastic surgeons scrambling to explain the situation to their patients. It is also caused breast augmentation patients already scheduled to choose a different breast implant manufacturer for their surgery.

The lack of any known safety issues makes this action by Sientra a potentially confusing issue for patients. To the best of my knowledge this whole event stems from the finding of microscopic particles discovered on the surface of the breast implants. What these particles are and their significance is unknown. But until their source could be determined, the manufacturing facility has stopped producing implants for now. It is my understanding that Sientra’s internal investigation has shown that these particles are silicon which is a normal and harmless constituent of the silicone polymer used in breast implants.

But to the credit of Sientra, they voluntarily suspended sales of their breast implants even though no patient safety issues have been identified from the incidental finding of these particles. Once this issue is fully clarified I expect Sientra breast implamt products to become available again in the very near future.

Dr. Barry Eppley

Indianapolis, Indiana

October 29th, 2015

Case Study – Jaw Asymmetry Correction with Custom Implant

 

Background: Symmetry of the lower third of the face, and the jawline specifically, is one of the most important components of facial aesthetics. Asymmetry in the jawline can occur in any of its components from the chin, body or ramus of the mandible. Differences in lengths of the ramus due to development is one of the major causes of jaw asymmetry. Since much of jaw growth comes from the condyle, it is not surprising that the adjoining ramus would be most commonly affected.

There are a variety of well known and classic jaw developmental abnormalities. Hemifacial microsoma is when one side of the jaw fails to develop properly and the face deviates towards the shorter side. Hemifacial hypertrophy, which is far more rare, occurs when one side of the jaw develops an overgrowth. The face is still very asymmetric but the face twists less and one side of the face looks more full although not necessarily deviated like that of hemifacial microsomia.

In extremely rare cases, both sides of the jaw are affected asymmetrically. One side of the jaw is demonstrably shorter while the other side is clearly longer. The exact cause of this type of growth disturbance is unclear although it is likely more of a lower jaw hypertrophy compared to a perhaps normal but naturally shorter opposite side.

Jaw Asymmetry Implant Design Dr Barry Eppley IndianapolisJaw Asymmetry Implant Thickness Dr Barry Eppley IndianapolisCase Study: This 20 year old female presented with facial asymmetry that was related to her lower jaw. A panorex and 3D CT scan showed vertical elongation of the right side of her jaw that pulled the inferior alveolar nerve down with it. There was a full 1 cm elongation based on the location of the mental nerve foramens. Computer imaging was done to determine if just one side of the jaw needed to be shortened, the other side just needed to be lengthened or whether a combination of both changes was needed. It was determined that her jaw asymmetry correction would be best done by a right inferior border osteotomy shortening and a vertical elongation of the left side. A custom vertical lengthening jawline implant was made from a 3D CT scan for the left side.

jaw asymmetry surgery intraop dr barry eppley indianapolisUnder general anesthesia and through intraoral incisions, an reciprocating saw was used to reduce 5 to 7mms off the lower end of the chin and jawline back to the angle. On the left side the custom jawline implant was inserted and stabilized by multiple small titanium screws.

Jaw Asymmetry Surgery results front view Dr Barry Eppley IndianapolisJaw Asymmetry Surgery results oblique view Dr Barryt Eppley IndianapolisHer 6 month results showed a much improved symmetry of the lower face. The inferior edges of the jawline were nearly comparable. There was still a slight asymmetry with the right side being slightly longer although it could not be further shortened without risk of injury to the intraosseous nerve location.

Jaw asymmetry correction requires a 3D scan and computer imaging to determine the optimal surgical methods for both sides. When the procedure should be done through an exclusive intraoral approach.

Highlights:

1) Jawline asymmetry can be caused by a vertical shortening or lengthening of one side of the jawline or a combination of both.

2) In bilateral jawline asymmetry lengthening of the shorter side and shortening of the longer side is needed for jaw asymmetry correction.

3) Jawline lengthening is best done with a custom made implant. Shortening of the longer side must take into account the location of the inferior alveolar nerve.

Dr. Barry Eppley

Indianapolis, Indiana

October 28th, 2015

Arterial Ligation in Temporal Migraine Surgery

 

While everyone knows what a migraine headache is, determining its exact cause in many patients is not so obvious. Recent advances in migraine care have been to determine if there is a specific extracranial cause that triggers the migraine. The focus has been on nerve compression of certain sensory nerves where they exit from the skull. These trigger sites include the frontal, occipital, temporal and nasal areas.

Temporal Migraine Surgery Dr Barry Eppley IndianapolisThe temporal migraine trigger site is the most perplexing due to a close association of vessels (anterior temporal branch), nerves (auriculotemporal and zygomaticotemporal) and the temporalis muscle and enveloping fascia. Many patients point to the temporal area as the origin of their migraines and often can pin point one very specific area.

temporal artery anatomy 2In the October 2015 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘The Current Means for Detection of Migraine Headache Trigger Sites’. In this paper the most interesting aspect of it was the section devoted to Doppler Signals. Since some of the sensory nerves can intersect or become intertwined with an artery, the migraine headache may be described as a throbbing type headache. This seems to be particularly true in the temporal area in my experience. Physical examination may demonstrate a pulsatile vessel and a hand held doppler unit can be useful to pick up the arterial signal at the site of the pain. This cause of some temporal headaches may be due to the anterior branch of the superficial temporal artery intersecting with the auriculotemporal nerve. But the doppler is also useful for isolating pulsatile flow in temporal areas that may not be considered traditional migraine trigger sites.

Doppler Probe in Temporal Migraines Dr Barry Eppley IndianapolisThe use of digital palpation combined with the doppler in the temporal region correlates with what I have seen in the aesthetic treatment of prominent temporal vessels.With ligation of some of the peripheral anterior branches of the superficial temporal artery, some patients will experience relief of their temporal headaches. While this arterial correlation may be more obvious due to the enlarged sizes of the artery, reduction of pulsatile flow works nonetheless.

Spot ligation of small temporal arterial branches is a part of temporal migraine surgery and can be an effective strategy for reducing certain types of pulsatile migraine headaches in temporal region.

Dr. Barry Eppley

Indianapolis, Indiana

October 28th, 2015

Nasal Septal Perforation Repair with Polydioxanone Plates

 

Septal perforations are an infrequent and unfortunate sequelae of septorhinoplasty surgery. Subperichondrial exposure of the septum for straightening and/or graft harvest risks disruption of the mucosal lining which may not fully heal if there is lack of cartilage underneath it. This is the root cause of any septal perforations which have a wide range of sizes from small (less than 0.5 cm) to quite large. (2.0 cms or larger) Symptoms from septal perforations include a whistling deformity, crusting, bleeding and having an odor.

While smaller septal perforations have a relatively high success rate of repair, as the size of the septal perforation becomes larger successful repair decreases precipitously. Many different methods of septal perforation have been proposed but they fundamentally consist of mucoperichondrial flaps with some intervening graft material. The most difficult aspect of this procedure is stabilizing the graft in place underneath the mucoperichondrial flaps.

polydioxanone plates in nasal septal perforation repair dr barry eppley indianapolisIn the October 2015 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Septal Perforation Repair Using Polydioxanone Plates: A 10-Year Comparative Study’. Twenty-five patients were treated with septal perforation repair of which over 1/3 (7) were treated with a method using polydioxanone (PDO) plates and temporalis fascia. Through an open septorhinoplasty approach with bilateral mucoperichondrial flap elevation, a piece of .15mm perforated PDO plate was used as a scaffold to attach temporalis fascia onto one side. The scaffold is placed with the fascia toward the open side of the perforation and the PDO plate opposite the mucosal flap closure. This septal perforation repair method is protected by silastic sheeting for six weeks afterwards to allow for complete remucosalization. The success rate was 75% (1 failure) regardless of septal perforation size.

The use of a PDO plate to aid in septal perforation repair is a sturdy and inexpensive scaffold to stabilize a temporalis fascial graft. The very thin plate is completely resorbable. It can be a valuable technical material addition to the treatment of medium to large septal perforations.

Dr. Barry Eppley

Indianapolis, Indiana

October 28th, 2015

Case Study – Lower Eyelid Ectropion Repair

 

Background: The lower eyelid is uniquely different from that of the upper eyelid. Besides being on the lower half of the eyeball, it has much less movement than that of the upper eyelid. The lower eyelid is largely static and is best thought of as a ‘clothesline’ running across the lower half of the eye. Being attached by the canthal tendons to the inside of the eye socket bones on each side, the lower eyelid is held tightly against the eyeball. By being right up against the eyeball, it serves to help keep the eye lubricated and provides a pathway for tear drainage.

Any surgery that involves the lower eyelid always runs the risk of disrupting its intimate and important relationship to the eyeball. While there are different eyelid incisional approaches, all have the potential to cause scarring and retraction pulling the eyelid down and away from the eyeball. (known as ectropion) Besides the obvious adverse aesthetic effects, loss of lid-eyeball contact leads to irritation, dryness and excessive tearing.

Reconstruction of lower eyelid ectropion can be challenging. It is almost never as simple as just ‘releasing the lower eyelid and pulling it back into place’. The lower eyelid layers are scarred and may be now short of supple tissue. Tissue grafting may be needed to overcome the scarred tissues and to prevent the pull down of the lower eyelid from recurring.

Case Study: This 40 year old female had a prior history of a left cheekbone fracture that was repaired by another surgeon. Six months after her repair the original surgeon removed her plates and screws used to fix the fracture and attempted to fix a lower eyelid ectropion. The eyelid ectropion repair was unsuccessful and actually became worse.

Left Lower Eyelid Reconstruction result front view Dr Barry Eppley IndianapolisLeft Lower Eyelid Reconstruction result submental view Dr Barry Eppley IndianapolisUnder general anesthesia a tranconjunctival and lateral canthal incisional approach was used. The lower eyelid tissues were released of all scar from the infraorbital rim. This created and internal conjunctival lining defect which was grafted with buccal mucosa. A lateral canthoplasty was performed using a double hole technique through the lateral orbital rim. Adjunctive procedures including fat injections to the cheek were also done to built up the tissues below the eyelid for typical fat atrophy that occurs after trauma.

Left Lower Eyelid Reconstruction result side view Dr Barry Eppley IndianapolisHer 6 months results that she achieved restoration of a competent lower eyelid that relieved all of her eye symptoms. The result is far from perfect as her lateral eyelid aperture ended up being slightly horizontally shorter than the opposite side.

Highlights:

1) Lower eyelid retraction can occur from a variety of surgical endeavors including cosmetic blepharoplasties and orbital and cheek bone fracture repairs.

2) Severe retraction with vertical shortening of the lower eyelid indicates a loss of eyelid lining os one or several lamellar layers.

3) Severe lower eyelid ectropion repair usually requires multiple surgeries with tissue grafting to achieve an improved horizontal lower lid position and good adaptation back against the eyeball.

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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