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.
May 16th, 2016
Pectus excavatum is a common congenital thoracic deformity that occurs in about 1:500 births. Males are more frequently affected than females. In severe cases it may be associated with pulmonary impairment but many pectus excavatum cases are cosmetic deformities. Given the importance of the appearance of the male chest it is no surprise that such thoracic deformities carry with them a significant psychological impact.
The most common surgical technique for the treatment of pectus excavatum are invasive and range from the historic radical cartilage resection to the contemporary Nuss procedure. While invasive the use of the Nuss bar does not remove rib cartilages and uses a metal bar to reshape the chest internally. But the bar does need to be removed secondarily and the degree of correction can often be incomplete. Better results are in the youngest patients where the rib cartilages are most malleable.
In the May 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published ‘Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases.’ In this paper, the authors report on their experience with a large number of silicone implants to treat funnel chests. Prior to 2007, implants were made from plaster chest molds. Since 2007 three-dimensional reconstructions were made from CT scans by computer-aided design. Only one infection and three hemtomas occurred. All implants developed some degree of periprosthetic seroma. Patients rated the appearance of computer-designed implants as much better than that of the plaster molds. The degree of correction of the chest deformity was also better corrected with the computer-designed implants. A Medical Outcomes survey showed significant social and emotional improvements.
A custom pectus excavatum implant made from a 3D CT scan can be a very good option for chest reshaping if one is opposed to any form of invasive thoracic surgery. While it is still surgery it done on top of the chest or from an extrathoracic location. Using a computer-aided design for the implants is superior to an external silastic elastomer mold because it is based on the actual shape of the underlying ribs and sternum. External molds are based on the shape of the external skin which does not have the detail of the underlying supportive cartilage and bone anatomy.
In this incredibly large clinical series in this paper, undoubtably the largest ever reported and probably done in the entire world, there were a surprising very low number of any complications. They did not report the need to remove any implants over the study period which is remarkable. This is a testament to how well the tissues tolerate an implant in an area of relatively low motion and stress exposure.
Dr. Barry Eppley
May 15th, 2016
Volume loss is a well recognized aspect of facial aging. This has led to a now popular and widespread use of facial volume augmentation techniques. Synthetic injectable fillers and fat are most commonly used since most of volume loss occurs in soft tissue compartments and these materials are easily placed by injection. The re-establishment of volume loss in the cheeks is often done as part of a facelift, for example, for an improved rejuvenative effect.
While injected fat or fillers can virtually be placed anywhere in the face, it is not always appreciated as to what the external effect may be. Since the face has well known soft tissue compartments, located in the deeper layers, it will have surface topographic effects based on the anatomic compartment boundaries.
In the May 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘Three-Dimensional Topographic Surface Changes in Response to Compartmental Voluminization of the Medial Cheek: Defining a Malar Augmentation Zone’. In this cadaveric study the authors injected a fat analogue into the deep medial cheek compartment. 3D analysis was done to assess the external volume changes on the face. They found that voluminization of this medial cheek region had distinct boundaries with the superior edge at the level of the arcus marginalis of the inferior orbital rim. When the arcus marginalis was released the upper edge of the augmentation zone was no longer restricted.
In this paper the authors have identified a very specific medial cheek zone that is often overlooked in facial volume augmentation. Its location is often part of a large area of volume loss that involves the tear trough region as well. Given its location over the medial orbital region and nasomaxillary skeleton, it is also an area that can be treated by facial implants as well. This requires a special type of facial implant design that I refer to as the extended tear trough implant.
The extended tear trough implant has one of its effects along the medial orbital rim for the classic tear troughs that many people develop or even have congenitally. But because the implant is designed to be placed intraorally, it has an inferior extension down over the medial maxillary wall. This puts it right under the medial cheek zone as described in this paper. Since an arcus marginalis release is needed to place the implant, its augmentation effect can cover two facial augmentation zones.
Dr. Barry Eppley
May 14th, 2016
Background: Chin augmentation is one of the most popular lower facial reshaping procedures and has been so for many decades. Its benefits are most commonly perceived in the side profile demonstrating increased horizontal projection of the chin. While changes in how far the chin projects forward is one of the most important benefits of a chin implant, that view alone is an inadequate perception of the overall chin augmentation effect.
Chin augmentation should be seen as a 3D procedure and not just a 2D one. This takes into account the frontal view as well, assessing the vertical and transverse dimensions. The frontal view of the chin includes its width which is highly gender specific. The female chin ideally has a amore narrow and tapered shape. Conversely the male chin is wider, more angular and can even have a square shape.
While there are numerous styles of chin implants, they have only two basic frontal shapes…convex and square. The square chin implant is unique in that it maintains a square shape when applied to the front edge of the chin bone which is usually convex. It does so because it is thicker on the sides of the chin so when pressed against the bone it maintains a square shape.
Case Study: This 45 year-old male had a chin implant placed several years previously through an intraoral approach. While it did improve his profile, he had been unhappy with how his chin looked straight on and he also felt it was sitting too high. He wanted more of a masculine square chin shape.
Under general anesthesia, his existing chin implant was removed through a submental skin incision. The implant was positioned high and was asymmetric in position. It was a central style of chin implant that was curved with no lateral wings. It was replaced with a style 1 square chin implant of similar anterior projection thickness. (7mms) A centrally placed 2 x9mm screw was inserted to ensure its central position low on the chin bone.
A square chin implant is uniquely made for men who desire a wider and more angular chin shape. It comes in two widths known as a style 1 and style 2 chin. In the style 1 the square chin width is 45mms and in the style 2 the square chin width is 55mms. Which style of square chin width is best for each patient depends on the horizontal width of their mouth and how strong they want the square chin to appear.
1) Chin implants come in both different styles as well as sizes.
2) When considering chin augmentation how the chin will look in the frontal view is often overlooked.
3) For men who seek a more angular and wider chin look, the square chin implant can help achieve this type of frontal chin shape.
Dr. Barry Eppley
May 14th, 2016
Background: Lost of a testicle in a male can occur for a variety of reasons. Congenital absence, an undescended testicle, infection, traumatic injury, varicoeles and other pathologies can all cause an absent scrotal sac on one side. While a man can fully function in all capacities with one testicle, there is psychological benefit for some men to feel and be seen as ‘whole’.
The creation of a normal paired scrotal sac can be done with a testicular implant. There are two types of such body implants currently available. An FDA-approved saline filled testicular implant an a solid silicone contoured caving block in the shape of a testicle. A solid silicone testicle implant is preferred in my hands because it is a permanent implant that will not fail or need to be replaced because of device failure. It can also withstand high levels of impact and compression without risk of rupture or implant deformation.
Case Study: This 35 year-old male lost his right testicle due to several years previously due to benign testicular tumor. He had an otherwise normal scrotal sac skin and had never received radiation for his tumor. Having only one testicle made him very self conscious and was a source of psychological concern.
Under general anesthesia, he had a size 4 testicular implant placed through a high scrotal incision of 3 cms. The soft compressible features of the implant made it possible to insert a 4.6 cm side implant through a much smaller incision than its width. The inserted implant had a fairly good size match to the opposite left testicle and a very similar feel as well.
Solid silicone testicular implants come in a variety of sizes with the maximum dimensions of 5 x 4 cms. Such an implant size may seem large but it is surprising how often it is needed when men are intraoperatively sized.
Men who are missing a testicle should find reassurance that it can be replaced with an implant that feels very natural in sizes that can match the opposite testicle. The implant operation is short with a similarly limited recovery time as well.
1) Reconstruction of a lost or congenitally absent testicle can be safely performed by a silicone testicle implant.
2) The best testicular replacement is a soft solid silicone testicle implant which can never fail or need to be replaced.
3) A silicone testicle implant can be placed through a small (3cm) skin incision placed high near the scrotal-groin crease junction.
Dr. Barry Eppley
May 10th, 2016
Custom skull implants have become a successful method for correcting many types of skull deformities where augmentation is needed. Interestingly, and perhaps not surprisingly, many aesthetic skull deformities are most apparent in men due to a ‘lack’ of hair. Whether the exposure of the skull is due to a shaved head, a short hair style or a thinning scalp cover, the shape of the skull becomes readily apparent.
Besides the shape and thickness of the skull implant design, it is especially important in custom skull implants in men to pay close attention to all edges of the implant. All of the implant’s edges (360 degrees) needs to be a feather edge. Even a 1 or 2mm edge will create a visible step off (edge transition) that will eventually be seen when all swelling subsides and scalp tissue contraction occurs around the implant. Early results after surgery in the first few months will appear smooth but by six months after surgery a visible edge may be seen.
When treating visible edge transition in an aesthetic custom skull implant, there are two traditional treatment options. The implant may be remade and a new one placed. Or the existing implant may be removed, the slight edge shaved down and reinserted. Neither of these two implant modifications options are particularly appealing.
Another option would be to perform fat injection grafting along the visible edge of the custom skull implant. Fat grafting is minimally invasive and can be performed with no significant recovery. While the scalp is not known to have a high fat graft take due to its inherent tightness, it does permit fat to be injected into it. In a single case in which I have treated a visible anterior edge of a custom skull implant with fat grafting, it’s visibility was essentially eliminated and persistently so at three months after the procedure.
Dr. Barry Eppley
May 9th, 2016
Rhinoplasty surgery can create changes in many aspects of the nasal anatomy. Most of those changes are typically focused on the bone and cartilage that makes up all of the internal and underlying support of the shape of the nose. The one exception to ‘framework’ modification is that of changing the shape of the nostrils.
Nostril shape change or alarplasty is most commonly done to alter the width of the nose. Known as nostril narrowing, the width of the nostrils can be narrowed by two basic techniques. It can be done by either removing skin from the nasal sill inside the nostrils or carrying the nostril skin excision around the sides of the nostrils for a more dramatic nostril shape change. The latter is usually done as part of many ethnic rhinoplasties.
But the position of the base of the nostrils can be changed in another dimension as well. They can also be lowered to a more inferior position as well. This is done by removing a crescent of skin which brings the nasal base lower when closed. Usually up to 4 to 5mms of lowering can be achieved.
Alar base lowering can be done for a variety of reasons. These can include too high an alar position after deprojection of the nasal tip, alar retraction due to scarring or contracture from prior nasal base or upper lip procedures, congenital deformities such as cleft lip and palate and combined with alar width reduction to affect a 3D alar base change.
Dr. Barry Eppley
May 9th, 2016
Background: Just like women, men have concerns about facial aging and undergo surgical procedures to improve their appearance. While men do have have facial rejuvenation procedures in the numbers that women do, they have surgery which historically is often later when the aging face problems may be more advanced.
There are numerous characteristics that separate men from women in undergoing facial procedures and facelift surgery is no exception. The key difference in this procedure in the presence of beard skin and the location and density of the hairline around the ear incisions. Keeping beard hair out of the ear and not making visible scars that stray far from the shadow of the ear are key considerations in surgical planning.
Case Study: This 47 year-old male presented after having had a ‘necklift’ by another surgeon. He had scars behind his ears but none in front of his ears. The scars behind the ear were low and back along the occipital hairline. He noticed no significant improvement from this type of necklifting operation.
Under general anesthesia, he underwent a more traditional lower facelift approach using a preauricular incision as well as his existing incisions behind his ears. A submental incision was also added to address the central neck area.
His one year after surgery results showed sustained improvement in his neck and jawline that looked natural. His surgical experience shows that neck and jawline improvement really can’t be achieved with incisions that are limited to just behind the ear. It is an appealing approach but without tissue undermining in front of the ear that permits an anterior axis of rotation, the neck and jawline can not really be improved.
The preauricular incision in the male facelift, while usually healing quite well, will shorten the distance of the non-beard skin area in front of the ear. This is unavoidable ut not usually detectable by most people.
1) The interest of most men in treating facial aging is in the neck and jowl sagging that develops
2) The male facelift usually uses a preauricular ear incision to avoid displacement of the beard skin onto the ear tragus.
3) Men seek a natural facelift result which has nearly undetectable scars and a smooth and non-tense skin appearance across the lower face and neck.
Dr. Barry Eppley
May 8th, 2016
Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.
The first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.
But some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.
The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.
Dr. Barry Eppley
May 8th, 2016
Aging presents in various ways at different facial areas. It usually affects the eye area first through the development of wrinkles, loose skin and herniated lower eyelid fat. Eventually the aging process extends down onto the cheek with the weight of the lower eyelid creating a clear demarcation between the eyelid and the cheek known as the palpebromalar groove.
In the Surgical Pearls section of the May 2015 issue of JAMA Facial Plastic Surgery, an article entitled ‘Short Incision Midface Lift in Lower Blepharoplasty’. In this retropective review, 80 patients by two surgeons were evaluated for their results with this lower blepharoplasty technique that provides aesthetic improvement to the aging cheek area. This modified lower blepharoplasty technique uses a short subciliary incision (mid-pupillary medially to 5mms past the lateral canthus), orbicularius muscle dissection and isolation, cheek mobilization, lateral canthoplasty/canthopexy, orbicularis muscle elevation and fixation to the orbital rim and conservative lower eyelid skin removal. The majority of patients (83%) had excellent and complications were few. The most common complication (5%) was lateral skin mounding. Only one case of ectropion occurred.
The improvement of the cheek with this technique comes from the reduction/elimination of the palpebromalar groove. This groove which appears as one ages can not be improved by non-surgical methods such as laser resurfacing or Botox injections. Injection techniques using either hyaluronic acid fillers or fat into the palpebromalar groove can be done but has a high complication rate of irregularities and contour problems. A better solution is reversal of the cause with re-elevation of the soft tissue descent and the re-establishment of a single midface convexity.
There are many midface lifting techniques that have been described. They differ by the extent of their incisions and dissection and how/where the mobilized tissues are suspended. This paper describes a more limited incisional approach that creates an orbicularis muscle flap that is sutured to the orbital rim. This is a more limited midface lift but in the right patient can be a useful facial rejuvenation procedure.
Dr. Barry Eppley
May 6th, 2016
Historically the choice for women considering breast augmentation were either saline or silicone devices. These very contrasting breast implants choices have very well known advantages and disadvantages. Saline breast implants offer the most economical approach to the procedure with aesthetic device issues such as rippling, an unnatural feel in some patients and the risk of an eventual dramatic and inconvenient failure event. Silicone breast implants offer an improved and more natural feel and no risk of a dramatic deflation event albeit at a higher surgical cost.
Along has come the Ideal implant which marries characteristics of both saline and silicone breast implants. The advantages of the Ideal breast implant over either traditional saline or silicone implants are numerous. They offer the benefits of both types of implants without any of their downsides. The Ideal implant has an external feel that is similar to that of silicone implants (no rippling) but without the use of any silicone filler material. For those women that may harbor some persistent concerns about silicone gel, this provides peace of mind. It will also not suffer a complete implant deflation which lets the patient know their implant has a problem (partial deflation) but yet will not go completely flat.
How does the Ideal implant achieve these improved physical characteristics over the traditional saline breast implant? It is in its proprietary and clever internal design. The implants has an internal structure which has an inner shell around the inner chamber which contains the inner saline filler and an outer shell around an outer chamber which holds the outer saline filler. Between these two shells are several baffle shells. This specialized type of inner structure controls the movement of saline inside the implant.
Even in a saline breast implant which has been filled to the point of stretching out the silicone containment bag (shell) and appears full, fluid does move around in waves inside it. But why does a traditional saline implant have ripples and feel so soft and extremely pliable? Using the well known Bernoulli’s Principle, the pressure in a moving fluid decreases as its speed increases, and increases as speed decreases. Thus the saline in a traditional implant moves very rapidly and therefore exerts a low pressure on the outer shell. The innovation of the Ideal breast implant is that its internal structure chambers and baffles slow the movement of the saline down and, as a result, increases the pressure on the outer shell which dramatically reduces wrinkling and makes it feel more firm. (like a silicone breast implant)
Such fluid dynamics also affect the shape of the implant. The Ideal implant maintains a higher profile with lower edges and better upper pole fullness than that of a silicone implant. It does not develop the so called ‘ash tray’ effect that almost all silicone implants do that occurs when the implant is laying on a flat surface.
Dr. Barry Eppley