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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.

January 11th, 2017

OR Snapshots – The Macroporous Custom Skull Implant

 

Custom skull implants have become a reliable and safe method of various types of skull augmentation. Made from the patient’s 3D CT scan, they cover the desired skull surface with a precise fit and a smooth outer surface that blends well into the surrounding bone/muscle areas. The most careful judgment has to be made in the thickness of its design so a competent and not overly tight scalp closure is obtained.

An obvious but often overlooked feature of most custom skull implants is that they are ‘large’. They can cover a significant surface area of the bony skull. This places an implant between the thick overlying scalp and the bone. While I have never seen this to cause any problems, it would be desirous to have some increased fibrovascular connections between the scalp and the bone. Since a silicone skull implant is not naturally porous this is not a biologic property such an implant would naturally have.

custom-skull-implant-ready-for-placement-dr-barry-eppley-indianapolisTo help achieve some integration of skull implants with the surrounding tissues, the concept of perfusion holes is used. This is were many 3mm to 4mm circular holes are placed through the implant. They can be thought of as ‘perfusion holes’. They will permit a very rapid tissue ingrowth through them, reconnecting the scalp and the bone with these tissue connections. They also serve to take one large implant pocket and make it many small pockets through this natural tissue quilting effect.

While these perfusion holes also help to fix the implant more securely into place, it does not make it any more difficult to remove or modify it later should the need arise. The tissue bands can be broken fairly easily in that process.

Dr. Barry Eppley

Indianapolis, Indiana

January 10th, 2017

The Custom Midface Implant

 

When most people (and many surgeons) think of midface augmentation, the use of cheek implants comes to mind. While cheek implants certainly do augment one area of the midface, they only cover one specific of the midface…the upper and outer corner of it.

Most of the midface lies between the cheeks and consists of the maxilla (upper jaw) and nasal base bones. From a bone standpoint midface augmentation is usually perceived as either a Lefort I or maxillary advancement (low midface) or a LeFort III osteotomy for a total midface advancement.

total-custom-midface-implant-dr-barry-eppley-indianapolisBut the midface can be augmented with implants just as effectively, or even more effectively, as moving the bone and way beyond what simple cheek implants can do. The use of a custom midface implant from a 3D CT scan can cover the entire midface from the pyriform aperture up to the cheeks. Such an implant can be inserted completely through an intraoral approach.

A custom midface implant is designed to increase central facial projection. It is an effective approach for patients with flat or concave facial profiles or for patients with negative orbital vectors. The point of maximum projection can be altered to either a low maxillary-anterior nasal spine point or higher up along the cheeks and infraorbital rims.

The typical ranges of increased midface projection for these custom implants is between 3mm to 7mms in most cases. Because it covers a broad surface area (the entire midface), its effect is greater than one would initially think.

Dr. Barry Eppley

Indianapolis, Indiana

January 9th, 2017

Supernumerary Nipple in Breast Augmentation

 

A extra nipple, in either men or women, is not rare. Occurring in up to 5% of the population, it is often mistaken for a mole due to its circular appearance. What separates it from a mole is that it is raised and has a textured and not a smooth appearance. It does not usually grow in size and only gets bigger in proportion to the body as it grows.

milk-linesThe location of a supernumerary nipple is also a giveaway as it will lie along the milk lines. The milk lines are embryonic vertical lines that extend from the armpit to the legs from which arise breast tissue and nipples. They appear early in embryonic life by the end of the second month in utero and well before sexual identity is formed. (hence why men have nipples even though they will never breastfeed) The nipples will form along this line and humans always have two nipples…although more are capable of forming along the milk lines.

In most cases of extra nipples, medically known as polythelia, it will just be a single one and is usually located below the breast or chest. Hence the term third or triple nipple. In more rare cases it will be more than just a nipple and it may develop into an actual breast mound albeit much smaller than a natural breast. (polymastia)

supernumerary-nipple-dr-barry-eppley-indianapolissupernumerary-nipple-next-to-augmented-breast-dr-barry-eppley-indianapolisGiven the relative common occurrence of an accessory nipple, it would not be rare to find it on a prospective breast augmentation. This is an example of a 35 year-old female who came in for breast implants and wanted to have a raised mole removed at the same time. Its appearance was clearly that of a nipple and not a typical mole. When removed at the time of surgery, its appearance can be seen to be similar to a nipple when laid up against the augmented breast.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Case Study – Asian Double Eyelid Surgery

 

Background:  The double eyelid surgery is a well known blepharoplasty technique that creates an upper eyelid crease in the typical Asian monolid. While the supratarsal fold is present in many ethnic groups around the world, it is missing in many Asian patients. The operation per we does not really create two upper eyelids or removes a single eyelid per se. But the placement of a crease creates two discernible upper eyelid sections which make it appear more interesting and even energetic.

While often called ‘westernizing’ the eyelid, this is not really the objective of the surgery nor is what most Asian patients want. Rather it makes the eye area more interesting than a monolid and is also a cultural sign of beauty. This accounts for its tremendous popularity in eastern Asian culture particularly amongst younger people.

There are a lot of variations in the Asian upper eyelid. It is common to see patients who have a hint or partial upper eyelid fold. Having some fold dictates where the new fold will be in most cases. Setting the new fold position can widely vary from its location above the lashline to its shape across the upper eyelid. There are numerous different techniques for creating the fold from no to a full incisional approach…each with their surgeon advocates.

Case Study: This 21 year-old female wanted double eyelid surgery to enhance her appearance. Her right eyelid was a monolid while the left eyelid had an incomplete crease, most promienently seen in the outer half of the lid.

asian-double-eyelid-surgery-intraop-dr-barry-eppley-indianapolisUnder general anesthesia, she had a full incisional double eyelid procedure using 5 points of levator-tarsal-dermal fixation for each eyelid. The crease height used was based on the of her incomplete crease level of the left upper eyelid. She declined medial epicanthoplasties. The immediate intra- and postoperative appearance can be striking with what appears to be creases that are too high.

asian-double-eyelid-surgery-results-front-view-dr-barry-eppley-indianapolisHer six months after surgery results show a pleasing upper eyelid appearance with defined creases and good symmetry between them.

Highlights:

1) Double eyelid surgery is an Asian eyelid procedure to make the upper eyelid more defined. (monolid to two distinct sections of the upper eyelid)

2) Many double eyelid procedures include treatment of the epicanthal fold as well. (medial epicanthoplasty)

3) Recovery from double eyelid surgery takes 3 to 4 weeks to see the final result

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Technical Strategies – Stacked Jaw Angle Implants

 

Jaw angles implants are designed to add size and shape to the mandibular ramus area. They are a companion and complement to the more commonly performed and well known chin implant. Together chin and jaw angle implants create a complete jaw augmentation approach.

While selecting the style and size of chin implants is fairly easy, doing so with jaw angle implants is not. Since the chin is a projecting structure on the edge of the jaw, the amount of horizontal projection is frequently the most important dimensional consideration. This is both easy to see, measure as well as perform computer imaging. Jaw angle implants, however, are not an edge enhancement procedure. Rather they provide augmentation to the side of the jaw/face where measurements and even computer imaging is harder to do in a reliable fashion.

Because of the more imprecise nature of jaw angle implant size selection, it is very helpful to be prepared during surgery with multiple implant sizes. Most of the time standard sizes will work (small, medium and large) but this is not always the case. How an implant looks in place can be less than what one would anticipate and there is always the issue of asymmetry which is very common in the jaw angle area.

stacked-jaw-angle-implants-technique-dr-barry-eppley-indianapolisIf necessary it is always possible to stack jaw angle implants together to create the desired augmentation effect. Unlike many other facial implant types, angle implants fit together fairly well… a little bit like nesting dolls. Some trimming does need to be done but the implants can be stacked fairly securely. This will increase the width of the jaw angle augmentation over what any one single implant can do.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

Zygomatic Arch Implants and the High Cheekbone Look

 

zygomatic-arch-sumental-viewThe zygomatic arch is the part of the cheekbone that extends back to the temporal bone in front of the ear. It is a thin bone and serves and looks like a bridge, allowing the temporalis muscle to pass underneath it. It can be thought of as the side of the cheekbone.  While it looks like a solid bone close inspection reveals a suture line in its middle, signifying it is formed by the union of the temporal process of the zygomatic bone and the temporal process of the zygomatic bone.

The word, ‘zygomatic’ is derived from the Greek word zygoma meaning bolt or bar….to join. The term has been used since ancient times and the arch part of the zygoma certainly joins the cheek to the temporal bone.

female-high-cheekbone-lookmale-high-cheekbone-lookWhile this facial bony anatomy is interesting, it is relevant in aesthetics to the structural basis of the high cheekbone look. This often exaggerated look to the cheeks creates a distinct line along the sides of the face. It is often seen in many male and female models and is a desirous facial feature for many patients seeking an improved and more symmetric facial appearance.

While numerous styles of cheek implants are available, none of them are designed to actually create the complete high cheek bone look. While they all add increased volume to the zygomatic body, none has any extension back along the zygomatic arch…which is the key to high cheekbone look.

large-zygomatic-arch-implants-design-dr-barry-eppley-indianapoliszygomatic-arch-implant-dr-barry-eppley-indianapolisZygomatic arch implants are designed to be used alone or in conjunction with standard cheek implants to create the high cheekbone look. These implants help to create an augmentation ridge from the cheekbone below the side of the eye back to in front of the temporal bone in front of the ear. Their posterior lengths can be adjusted to either stop in front of the temporal hairline or go back further into it.

When placing zygomatic arch implants it often takes more implant size than one would think. More than a few millimeters in height and width are needed in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

January 8th, 2017

OR Snapshots – The Open Rhinoplasty

 

Rhinoplasty surgery requires incisional access to perform osteocartilaginous reshaping. The most common historic technique was the ‘closed approach’ where all incisions were placed inside the nose. Because this provided limited visual access it took a lot of experience to master aesthetic nasal surgery. This was the standard in rhinoplasty until the 1990s were it was surpassed in usage by the ‘open approach’.

open-rhinoplasty-indianapolis-dr-barry-eppleyThe open approach degloves the skin off the tip of the nose and permits complete visual access to the entire underlying nasal structures. What makes it possible to expose the nose is the mid-columellar incision. This extra 6mms of skin incisional length connects with intranasal mucosal incisions to allow the nasal tip skin to be lifted off of the lower alar cartilages. While once controverial, the open rhinoplasty has become the standard technique in rhinoplasty today as it produces consistent and more reliable surgical outcomes.

Patients are often understandably concerned about a visible nasal scar with the open nasal approach. But the columellar skin heals so well that such a scar is virtually invisible in most patients. It rarely causes a scar problem and I have never seen a hypertrophic or keloid columellar scar. The only occasional columellar scar problem seen is a stepoff or notch along one of its sides due to less than perfect closure or premature incisional separation.

Interestingly, the widespread use of the open approach has led to a re-emergence of the closed approach. Now known as the ‘scarless’ rhinoplasty, the use of the closed approach is refinding a role in certain types of nasal reshaping surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2017

Case Study – Older Female Jaw Angle Implants

 

female-strong-jawline-dr-barry-eppley-indianapolisBackground: The strength of the lower jaw is a known favorable feature for a male. But it has become increasingly desired and requested for women as well. Partially spurned on by various well known celebrities and actresses’ jaw shapes, younger women are seeking stronger jawlines as well.

An important part, and until recently overlooked, of a well defined jawline is the jaw angles. When patients refer to a ‘stronger jawline’ they are usually referring to the jaw angle area. A well defined and prominent jaw angle is one that is clearly seen from the front view and often creates more of a V-shape to the jawline. While once considered more masculine, a female with more prominent jaw angles are now seen as youthful and atractive.

One unexpected but favorable effect of jaw angle augmentation is that it provides a lift along the jawline. Making a stronger jaw angle requires increased soft tissue coverage. This recruits tissue from the neck to cover the increased bony prominence. This can have a favorable effect in the older patient who has developed loose skin along the jawline and posterior neck.

Case Study: This 61 year-old female was to undergo a variety of facial rejuvenation procedures. One of her requested procedures was jaw angle augmentation. She wanted more defined jaw angles and v-shaped jawline. She previously had a facelift.

female-jaw-angle-implants-result-front-view-dr-barry-eppley-indianapolisUnder general anesthesia, she had medium widening jaw angle implants placed through posterior intraoral incisions. The implants were placed under the masseter muscle, snuugly fitting up against the existing bone angle posterior and inferior contour.

cw-jaw-angle-implants

A more sharply defined jaw angle has both a jawline reshaping effect and a lower facial rejuvenative influence in older patients. Even in the older female patient who has already had a facelift, a stronger jaw angle adds to a rejuvenated jawline.

Highlights:

1) Jaw angle implants add shape and definition to the back part of the jaw/lower face.

2) Females are having an increased interest in the shape and definition of their jawline.

3) In older females a stronger jaw angle can fill out loose skin and give a bit of a facial rejuvenative effect.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2017

OR Snapshots – The Bifid Nasal Tip Rhinoplasty

 

The shape of the nose amongst people is as different as that of fingerprints. Between the innumerable size and thicknesses of the bone and cartilage that make up the nose and its thick or thin skin cover, the variability in nose shapes is endless. What rhinoplasty can do is to change the shape and thicknesses of the supporting bone and cartilage framework onto which the skin covers it. The skin of the nose is rarely, if ever, surgically altered by removal.

bifid-tip-rhinoplasty-dr-barry-eppley-indianapolisOne of the classic examples of how the shape of the nose comes from its structural framework is that of the bifid nose. This is where a cleft or groove exists down through the center of the tip of the nose. It separates the nasal tip into two discernible halves. It is not an uncommon nasal tip deformity. It can occur in nasal tips that are both narrow and wide and results from a separation of the lower alar cartilages from the tip down to the base of the columella. In this open rhinoplasty surgery the cause of the groove down the nasal tip can be seen from the wide spacing between the medial footplates of the columellar cartilages.

Repair of the bifid nasal tip is done by closing the gap between the separated cartilages through suture techniques in an open rhinoplasty approach. In some cases a cartilage graft (columellar strut) may also be used to fill in the gap. As the skin follows what the cartilage looks like underneath the groove on the skin disappears after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2017

ePTFE Nasal Implants

 

Augmentation of the nose can be done by a variety of rhinoplasty techniques and materials. When possible, one’s own cartilage is always the best from a biologic standpoint and is preferred if it can provide a satisfactory aesthetic outcome. The use of septum, ear and rib cartilages offer a wide variety of graft choices that can meet almost every type of nasal augmentation need.

But there are circumstances where the use of autologous cartilage in the nose is not an option. It is almost always due to patient preference or convenience as the supply of cartilage from the ribs is virtually endless given the small size of the nose.

nasal-implants-dr-barry-eppley-indianapolisImplants offer a preformed approach to nasal augmentation with emphasis on raising up the dorsum. A silicone nasal implant is the most commonly used facial implant in the world and comes in a variety of shapes and sizes. While implants in the nose has its own risks and disadvantages (as well as its surgeon critics), in the properly selected patient it can create very pleasing aesthetic results that have good long-term persistence and a low rate of complications.

A silicone implant has the advantage of a preformed shape that will never change and it is easy to surgically insert due its smooth surface. Its smooth surface also creates a low rate of bacterial adhesion due to lack of surface attachment points. The disadvantage to its smooth surface is that it does not allow for tissue ingrowth or tissue attachment.  Thus the implant develops a smooth encapsulating layer of tissue into which the implant passively resides. Without being fixed into the recipient tissue bed, there is always the opportunity for implant shifting, tissue thinning and even infection.

eptfe-nasal-implant-on-skull-dr-barry-eppley-indianapolisOne modification that has been useful to the silicone nasal implant is a coating of ePTFE. (expanded polytetrafluoroethylene) Originally known as Gore-tex, ePTFE creates a coating on the implant that has a microporous structure due to its microfibrillar structure. This creates a nasal implant, which has all the advantages of pure silicone, but also creates the opportunity for tissue attachment/adherence.

eptfe-nasal-implant-shape-dr-barry-eppley-indianapolisePTFE nasal implants offers a near perfect dorsal implant for rhinoplasty surgery. Its smooth surface and saddle-like design provides a good fit for most nasal dorms. Its placement ensures that the nose will be straight and smooth and have good aesthetic lines. Soft tissue adherence will stabilize the implant long-term. While the soft tissue adherence is not as good as would occur with cartilage graft, it makes the silicone implant a little more like a graft than an implant.

nasal-implant-rhinoplasty-result-side-view-dr-barry-eppley-indianapolisePTFE nasal implants are a good choice in dorsal augmentation rhinoplasty in which the straightness of the result needs to be most assured. As long as the implant is not too big or stresses the nasal skin excessively an uncomplicated long-term result should occur.

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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