EXPLORE
Plastic Surgery
Dr. Barry Eppley

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

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

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

October 9th, 2017

Five Concepts about Temporal Reduction (Wide Head Narrowing Surgery)

 

Reduction of the wide head is a procedure primarily performed by removal of the posterior temporal muscle. (temporal reduction) Besides the fact that few patients and surgeons even know such an aesthetic operation can be performed or exists, it is common that those who discover it grapple with why it works or have concerns about potential adverse functional facial effects. From that perspective let me address five concepts about temporal reduction surgery.

The Width of the Posterior Temporal Muscle Is Bigger Than One Thinks. The thickness of the side of the head above the ears is composed of three main tissues; skin, muscle and bone. While the temporal bone does make a major influence on side of head convexity, the posterior temporal muscle can often make up 40% to 50% of its thickness as well. In many male patients I have seen the muscle be 7mm to 9mm in thickness per side.

A Vertical Line from the Top of the Ear is the Excision Boundary. The anterior extent of the posterior muscle removal is determined by this line. Albeit somewhat arbitrary as there is more real defined transition between its anterior and posterior bellies, it is were the muscle starts to become much thicker. It is also a convenient point of access from the postauricular sulcus incision placed behind the ear.

Removal of the Posterior Temporal Muscle Causes No Jaw Dysfunction. Seemingly defying the purpose of its very existence, no long or even short-term jaw dysfunction has ever been encountered. If the patient opens their mouth really wide in the first day or two they may feel so tightenness/discomfort but this quickly passes. Undoubtably this occurs because the much larger anterior muscle belly remains (it makes up 70% of the overall temporal muscle mass) and the posterior belly makes an adjunctive but not essential contribution to jaw movements.

The Overlying Fascia of the Posterior Temporal Muscle is Preserved. Keeping the tight overlying fascia allows it to have a contouring effect. Initially the cut edge of the muscle will have a palpable step-off. The overlying fascia has a dampening effect on the remaining muscle edge and acts as a barrier to prevent skin adhesion directly to the now exposed bone. Its preservation also maintains the overlying vascular pedicle of the posterior branch of the superficial temporal artery.

Posterior Temporal Muscle Removal Takes Six Weeks To See Its Final Result. The dressing applied right after surgery is removed the following day. At its removal the flattening result is immediately apparent and usually satisfying. But then the swelling sets ion and it will be another 6 to 8 weeks before the initial result seen recurs.

Dr. Barry Eppley

Indianapolis, Indiana

October 9th, 2017

Case Study – The Limited Facelift Concept

 

Background: One of the most recognized anti-aging facial procedures is that of the facelift. While commonly recognized it is not commonly understood by the public. Many misconceptions exist about this operation from how it is performed, its immediate and long-term facial effects and to who may even be a good candidate for it.

The facelift procedure has been around for over 100 years and its medical name, rhytidectiomy or the removal of facial wrinkles, speaks to its age. In its original use it was designed to remove wrinkles from the face by cutting out skin in front of the ear or temple area. The operation has certainly evolved since its inception, due to improved anesthesia and surgical techniques, and it has become as much about repositioning of lax facialk tissues as it is about cutting them out.

Despite the evolution of the modern day facelift and its myriad of technical maneuvers within the operation, there are still some basic components to it. The extent of skin flap elevation in the face, how the SMAS layer is managed and how much central neck work is done allows for the facial procedure to be divided into three types or levels whose application depends on the extent of the patient’s aging facial tissues.

The limited or mini-facelift, aka level 1 procedure, has become popularized under a variety of marketing names. Because it is a more limited operation it has become promoted for its quicker recovery, shorter operative times and execution under more limited anesthesia methods. By definition such intra- and postoperative sequelae occur because the operation is less invasive. Less surgery is done, thus making everything about this type of facelift ‘less’ even including cost.

Case Study: This 45 year-old female wanted to reverse some adverse changes that had occurred in her neck and jawline. She had developed some jowls as well as some neck skin laxity occur with some platysmal banding.

Under general anesthesia, she had a limited facelift performed with short skin flaps raised in front of the ear and down into the neck but did not extend to the central neck. A short SMAS flap was raised with suture suspension. A submental incision was made to release and tighten the platysmas bands. Her six week results show a smoothing of the jawline and an improved neck angle.

Any ‘limited facelift’ technique is, by definition, a limited version of its more complete form. What makes it easier in every aspect is that it is less surgery. While that may seem obvious it it important for patients to understand that, while everything about the operation is appealing, it will not create the same result as its much larger form. It works best when the operation is matched to the anatomic problem. For patients with greater neck sag, jowls and overall tissue descent, this operation will not meet one’s expectations. In short a limited facelift is not a full facelift.

Highlights:

  1. A facelift is a variable operation whose extent is based in the aging anatomy that it needs to treat.
  2. A limited or mini-facelift is usually defined as a procedure that does not include the full neck dissection and/or has limited skin flap elevations.
  3. Most more limited facelifts are best done ion younger patients who have earlier rather than advanced signs of facial aging.

Dr. Barry Eppley

Indianapolis, Indiana

October 8th, 2017

Product Reviews – Botox for Forehead Wrinkle Lines

 

Botox is the most popular form of injectable aesthetic therapt. It has an established history of success in managing problematic facial movements that cause undesirable facial expressions and ultimately skin wrinkles. It was formally FDA-approved well over a decade ago for the treatment of glabellar (between the eyebrow) wrinkles lines and has gone on to receive a similar FDA-approval for crow’s feet wrinkles as well.

Even though formal approval for other types of adverse facial wrinkles and expressions did not exist, Botox has been long been done ‘off label’ by just about every injector that has ever used it. Other aesthetic facial issues such as in horizontal lines across the upper nose (bunny lines), in the neck for platysmas bands as well for the downturned mouth corners, to name a few, are widely done.

Recently Botox was FDA-approved for the treatment of horizontal wrinkle lines. Long a companion injection site with that of glabellar wrinkle lines, it now official that it can be used in this facial area as well. It has been common to treat vertical glabellar and horizontal forehead lines as a combined injection treatment. I would say that it is more common to treat both areas together that it was to treat the glabellar area alone.

What does FDA-approval of this Botox use really mean? It really just substantiates what every injector has observed…that is both safe and effective for use in the forehead. Clinical trials reported by Allergan demonstrated that Botox injection was more effective than a placebo in reducing the severity of forehead lines.

Botox injections creates this forehead effect by temporarily weakening the frontalis muscle which runs vertically across the forehead. Less frontalis muscle movement softens existing deep wrinkles lines and prevents new ones from forming. Its duration of effect is the same as anywhere else on the face with an effect of three to four montyhs.

Dr. Barry Eppley

Indianapolis, Indiana

October 6th, 2017

Case Study – Sliding Genioplasty Combined with Chin Implant

 

Background: Routine chin deficiencies are well managed by with an implant or a sliding genioplasty. The concept of a routine chin augmentation, in my experience, generally falls into a horizontal chin position movement of 10mms for less. Once the aesthetic need becomes greater than a centimeter there is undoubtably an overall lower jaw skeletal deficiency that should ideally managed by a combined orthodontic-orthognathic surgery approach.

But some lower jaw deficient patients will never undergo movement of the entire lower jaw and teeth positions for a variety of reasons. They may appear just for chin augmentation only as a camouflage approach to their lower facial deficiency.

While a large chin implant can be used, most standard chin implants do not provide more than 10mms of horizontal advancement. While larger custom chin implants can be made, such a load of synthetic material on the chin may exceed the soft tissue stretch to safely accommodate it. The projection off such a large chin implant may also appear unnatural with a much thinner jawline behind it.

A sliding genioplasty can usually exceed 10mms if the bone thickness will allow it. I have seen it often go to 14 to 16mms. But in such large tiny chin movements there will be pronounced stepoffs on their sides and the labiomental fold will definitely get much deeper as the bone underneath it has become deeper as the lower chin point comes forward.

Case Study: This young male has a large chin deficiency with a skeletally short lower jaw. From an ideal chin projection standpoint for a male (vertical line dropped down from the lips) he was 22mms horizontally short. Orthognathic surgery was not an option that he wanted to pursue.

Under general anesthesia, an intraoral sliding genioplasty was performed with 14mms of horizontal advancement based in the limits of maintaining bone contact. (lingual cortex of lower chin segment with buccal cortex of upper chin segment) To add a little extra to the what moving the bone achieved a 5mm extended anatomic chin implant was placed in front of the front edge of the chin bone. The wings of the implant went back along the sides of the advanced chin segment across the step off area. Due to the large step-off created an hydroxyapatite block was placed to prevent a severe deepening of the labiomental fold. (the fold is always going to get deeper in larger chin augmentations, you just want to try and lessen that effect)

The need for a combined sliding genioplasty and implant for aesthetic chin augmentation is rare and is avoided by the traditional use of orthographic surgery. The value of such a chin implant is three-fold; 1) its a small amount of additional horizontal augmentation, 2) its wings can cover up the indentation along the sides of larger sliding genioplasty movements (the concave jawline deformity) and 3) it keeps the chin from looking too thin in the frontal view.

It is not a mortal surgical sin to combine two chin augmentation methods that are often viewed as competitive procedures. Each has their own distinct aesthetic effects and in rare cases may be used synergistically to create a better aesthetic outcome than either one can achieve alone.

Highlights:

  1. Large chin deficiencies are often beyond what a sliding genioplasty or a chin implant can effectively treat alone.
  2. Combining a sliding genioplaty with a chin implant can maximize the amount of horizontal advancement and cover bony step offs on the sides. 
  3. Large sliding genioplasty movements will require fill of the step-off to avoid a severe deepening of the labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

October 2nd, 2017

The Cause and Treatment of the Upper Lip Horizontal Crease

 

The upper lip is subject to a variety of lines and wrinkles as one ages, particularly in females. The vertical lines of the upper lip are the most recognized and are due to the activity of the sphincteric orbicularis muscle. Another type of aging line is that of the horizontal upper lip crease. While less common, it is also due to hyperactive muscle action of which the depressor septi nasii muscle has been implicated at its cause.

Yet injections of Botox into the depressor septi nasi muscles does not cause the upper lip crease to be improved, suggesting other lip muscles are at fault. Or at least the creation of the upper lip crease involves a more complex interaction of other lip muscles than is currently thought.

In the October 2017 issue of the European Journal of Plastic Surgery an article entitled ‘Prevalence of  Transverse Upper Labial Crease’ was published. In this article, the authors studied one hundred (100) females to determine the presence and location of an upper labial crease at rest and smiling. In women over 40 years of age over one-third had an upper lip crease at rest and nearly three-quarters had it with smiling. The location of the crease varied from at the columellar base to the lower third of the lip. It occurred most commonly in women with a ‘big’ smile due to a strong levator labii superior muscle action. Therefore the injection of Botox is proposed as a method to treat the aesthetically undesirable upper lip horizontal crease.

The levator labii superioris is a muscle of facial expression that elevates and everts the upper lip. Its origin is from a bony attachment at the superior edge of the upper jaw (maxilla) and descends inferiorly into several slips of muscle into the upper lip. Multiple insertions for these muscle slips have been described from the nostril medially to the zygomatic head laterally. Looking at the length of many upper lip labial creases, it makes anatomic sense that the more central depressor septi nasii muscle can not account for the full length of the lip crease.

This anatomic description for the basis of upper lip horizontal skin creases can be easily tested by injecting Botox into its insertion points. As the authors have stated this does create some lessening of upper lip creases. By weakening of the upward pull of this muscle the patient should be aware that their smile arc may not be as great and the upper lip have increased lengthening. 

Dr. Barry Eppley

Indianapolis, Indiana

October 2nd, 2017

Case Study – Helical Rim Lengthening in Setback Otoplasty

 

Background: The shape of the ear is complex and its affected by how its cartilage structure becomes formed during its embryologic development. With its array of folds and concavities the ear assumes a unique shape for each person. In addition to its shape,  its size and orientation to the side of the head affects how visible it is when seen in the frontal view.

The most visible part of the ear is its outer edge known as the helical rim. Formed from contributions of the embryologic Hillocks of Hiss #s 3,4 and 5, the outer rim becomes the leading edge and the most protruding level of the ear.  The length of the helical rim affects both the size and protrusion of the ear.  As an encircling anatomic feature, the smaller the helical rim is the smaller the ear may be for it may make it stick out more, depending upon how shortened it is.

In the protruding ear there is always some degree of helical rim shortening although much more minor than in the truly constricted ear. This perceived effect is caused by the lack of a well defined antihelical fold. Without an antihelical fold the outer helical rim becomes folded over or shortened.

Case Study: This teenage female was bothered by ears that stuck out  and they were a source of embarrassment for her. She had a well formed concha which was not excessive.

Under general anesthesia bilateral otoplasties were performed with the total focus on improving the shape and definition of the antihelical fold. Using permanentt horizontal mattress sutures through a postauricular incision, the creation of the antihelical fold brought back the ear into better alignment with the side of the head.

With a setback otoplasty achieved through antihelical fold creation, the length of the helical rim actually becomes longer. Such helical rim elongation allows the ear to set back further against the side of the head in a less conspicuous manner.

Highlights:

  1. Otoplasty surgery is most commonly done in children and teenagers to correct protruding ears.
  2. The most important principle in protruding ear correction is elongating the helical rim to move its outer portion closer to the side of the head.
  3. Antihelical fold  manipulation is the only technique for helical rim elongation.

Dr. Barry Eppley

Indianapolis, Indiana

September 28th, 2017

Hand Rejuvenation with Injectable Fat Grafting

 

Fat grafting through an injectable technique has enjoyed widespread popularity over the past decade. Because of its ubiquitous presence throughout the human body and its relatively easy extraction by liposuction, fat injections have been done in just about every external feature of the human body. In addition to its volumizing capability, such injected fat has also been shown to have some skin rejuvenation properties as well.

Aging of the hands is characterized by loss of fat and skeletonization of its structural components with thinning and wrinkling of the overlying skin. The introduction of one’s fat into the dorsum of the hands, therefore, may be viewed as the best form of hand rejuvenation. The fat reinflates the back of the hands and as yet unknown factors contained within the fat contributes to skin rejuvenation as well. 

In the October 2017 issue of the European Journal of Plastic Surgery an article entitled ‘Hand Rejuvenation with Fat Grafting: A 12-year Single-Surgeon Experience’. In this article, the authors present their protocol for hand fat grafting with over a decade of clinical experience in doing it in 65 patients. Fat is harvested in a standard fashion and is prepared without centrifugation. (decanting) It is injected in a proximal to distal approach above the dorsal deep fascia and between the 1st and 5th ray. The average amount of fat injected ranged from 10 to 30 ccs. The majority of patients (84%) were satisfied. Picture results at one year show that they average fat take was high. Other than some temporary prolonged swelling in a few patients, no long-term complications were seen.

This clinical paper with good patient volumes show that fat takes fairly well in the thin tissues of the back of the hand. This may seem a bit surprising given that the natural fat layer is very scant in this body area. The biggest issue in fat grafting to the hands in my experience is not how well the fat takes but in making sure it has been placed in a smooth a layer as possible to avoid lumps or an irregular contour. I find that digital molding of the fat or using a roller helps in smoothing out the fat injectate.

With fat grafting for hand rejuvenation, it should not be forgotten to treat the outer skin as well. Fat injections can be combined with laser and chemical peeling to improve the skin texture as well as BBL (broad band light) to help treat brown spots.

Dr. Barry Eppley

Indianapolis, Indiana

September 27th, 2017

Technical Strategies – Buccal Fat Grafting of the Labiomental Fold

 

The labiomental fold is a small and often overlooked facial feature. Lying between the lower lip and chin, it is a crease or fold of varying depths amongst different people. Why a labiomental fold even exists at all is a function of many factors including chin projection, the attachment of the mentalis muscle to the bone, the size of the soft tissue chin pad, the depth of the intraoral vestibule and the size and projection of the lower lip.

While often thought irrelevant, it becomes a more important aesthetic issue in chin surgery particularly that of augmentation. Since the labiomental fold is a fixed anatomic structure, its appearance will be affected by increasing chin projection almost regardless of the method to do so. As the inferior chin comes out further, the superior labiomental fold by contrast will look deeper. There is nothing a chin implant or a sliding genioplasty can do, on their own, to make the labiodental fold less deep.

Softening a deep labiomental fold requires a direct approach whether it is an injection technique or an implant. Injecting filler or fat is often not rewarding as the tightness of the fold makes it hard to get a good push outward.

An alternative strategy is to perform a full release of the dermal attachments of the fold above the mentalis muscle through an intraoral approach and then place a soft tissue graft. A fat graft is a good choice for the filler material and can come from a variety of sources including a dermal-fat graft and a solid fat graft like that from the buccal fat pads. (as shown here)

Release of the deep labiomental fold well above the bone level (north of the mentalis muscle and not south of it) is the key for successful fat grafting in efforts to soften it.

Dr. Barry Eppley

Indianapolis, Indiana

September 27th, 2017

OR Snapshots – Double Stacking Chin Implants

 

Chin implants are the original and still today the most common form of facial skeletal augmentation. Having been around for over fifty years in various forms, chin implants have undergone many evolutionary changes in their shapes to satisfy a wide variety of aesthetic chin needs. Because of its history and frequent use, they have the greatest number of different styles and sizes off any type of facial implant.

But even with such a diversity of standard options, not every patient will do well with an off-the-shelf implant shape. This is where the role of custom implants comes into play where any dimensional need can be addressed through patient specific designing for unique chin dimensional augmentations. While extremely effective custom facial implants come at an increased cost over standard ones that may be a limiting factor for some patients.

While chin implants can be modified by hand carving them during surgery, adding to them is a different matter. There is no recognized method for increasing the size or shape of a standard chin implant. In some situations I have found it effective to marry together two different implant styles to get the desired effect. This is an example where a prejowl implant is added to an anatomic implant to get wider wings for more prejowl augmentation. By suturing the implants together in multiple locations, shifting or one implant sliding off of the other is prevented.

It is acknowledged that the use of 3D imaging and implant designing is best for most unique chin augmentation needs. But in the right circumstances it is possible to create a ‘semi-custom’ chin implant using standard implants in a stacking technique with suture fixation.

Dr. Barry Eppley

Indianapolis, Indiana

September 27th, 2017

OR Snapshots – The Customizable Custom Skull Implant

 

Custom made skull implants are the best way to perform almost any type of skull augmentation. Covering potentially large surface areas of the skull in a smooth manner is very difficult when attempted by traditional bone cement materials. The computer designing process does what no surgeon can do as well with the naked eyes and their own hands. While the computer design process can make whatever implant dimensions the surgeon chooses, the question is always what exact aesthetic will it create and whether this aesthetic result meets the patient’s head shape goals.

In some rare cases the patient may desire some reductive modifications to their skull implant. (additive modifications usually require a new implant) This is most likely to occur after the implant is in place or after the patient has ‘worn it for awhile’. Like all other facial implants such modification is possible through an implant shaving process. Unlike facial implants, however, the skull implant has a much large surface area which makes it more challenging to make the changes smooth and even on a curved surface. This requires a larger than normal scalpel blade and good experience in such implant manipulations.

Most commonly reduction of a custom skull implant is to reduce a certain area of thickness or to remove one of its contours. Such reductions need to be done over a much larger surface area of the implant than one would think. As a result it also requires a wider amount of incisional exposure than one may want to do. But good results from such implant modifications come from not trying to do so from limited exposures where visibility is compromised and the pocket for instrument manipulation is too restrictive.

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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