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.

February 11th, 2018

The Anatomic Basis for Custom Infraorbital-Malar Implants

 

The cheeks occupy a prominent aesthetic position in the midface. They create some amount of facial prominence/angularity as they curve around between the eye and the side of the face. While the cheek is often perceived as an isolated circular area by the side of the eye, as is commonly seen in the shape of most standard cheek implants, this is not how this facial area is anatomically constructed.

The cheek or malar region is an aesthetic term of which its bony anatomy is more extensive than the name implies. The zygomatico-maxillary-orbital bone complex is the bony foundation of the cheek. It is not an isolated bony area but a long stretch of bone that runs from the temples posteriorly to the infraorbital rim. This can be appreciated by those people who have or seek the ‘high cheekbone’ look.

It should be not surprise, therefore, that undereye hollows are associated with flatter cheeks as well given that they are part of the same bony region. When treating undereye hollows by implant augmentation it would be very uncommon that infraorbital augmentation is done alone. It is always best done by more of a wraparound implant design that provides a continuous and blended stretch of augmentation which is the anatomic basis for custom infraorbital-malar implants.

Custom infraorbital-malar implants are placed through subciliary lower eyelid incisions. This provides the most direct access for the linear dissection that is needed from the nasal bones medially to the posterior end of the zygomatic arch. It is interesting how long or large such an implant can look when placed on the face compared to how it looks on the bone in a 3D design.

Saddling on the infraorbital rim rather than just sitting in front of the bone is part of the smooth continuous design and is an important design feature than provides the best improvement in undereye hollows. This part of the implant is secured to the infraorbital rim with small microscrews. Assuring a good fit along the infraorbital rim is critical as this determines how the long hidden wings of the implant over the zygomatic body and arch will be positioned.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2018

Case Study – Female Crown of the Skull Augmentation with a Custom Implant`

 

Background: The shape of the head in a female has important aesthetic significance. While the concept of having a ‘nice round head’ is perceived as an ideal head shape, the ideal woman’s head shape is much more of an oblong shape. But the area over the crown of the head is of particular significance as it should be the highest peak of the skull in women. This is quite unlike men who would view such a location of maximal skull height as an unaesthetic protrusion.

Why women like a more prominent crown of the head is not precisely clear. At the least they do not like a crown area that is flatter or lacks projection. It may be its appeal from is influence on how it pushes the hair upward. This is suggested because many women who undergo crown augmentation talk of the tedious nature of teasing their hair to look like they have a higher crown area of the head.

Creating a higher crown of the head can only be done by building up the skull. Between bone cements and implants, these are the only two effective augmentation options. While fat grafting has become popular for injectable soft tissue augmentation, this technique will not work for skull augmentation as the scalp is too tight to be pushed outward by the soft consistency of fat. Custom made implants from the patient’s 3D CT scan has become the most effective technique to ensure the best augmentation shape and the desired area of skull coverage.

Case Study: This young female was bothered by the flat area over the crown of her head. A 3D CT scan showed how her skull shape sloped downward over the crown area as well as a triangular shape from the front view.

From the 3D CT scan a custom implant was designed to cover the crown area and give a more convex shape. The maximum central projection was set at14mms which was felt to be as much as the scalp could stretch in a one-stage implant augmentation.

Under general anesthesia and in the prone position, a 9 cm horizontal zigzag scalp incision was made over the nuchal ridge of the occiput. A subperiosteal pocket was made way up over the crown area. To keep the incision as limited as possible it is necessary to fold the implant for insertion. In thicker skull implants that are 1cm or over in the area of maximal projection, it is helpful to create a tighter implant roll to remove strips of material on its inner surface parallel to the direction of the implant roll.

The implant is then inserted in a rolled fashion and unrolled and positioned once inside the pocket. The compass marker on the implant serves as a key guide for proper implant positioning and midline alignment as this is the only part of the implant seen through the incision.

A custom skull implant is the most assured method for a higher crown area for women, creating the so called ‘bumpit’ effect. The firm composition of the implant provides the best push on the overlying scalp creating a permanent long-term augmentation effect.

Highlights:

1) The flat back or crown of the head is the common location for aesthetic skull augmentation.

2) The maximum thickness of the implant’s central projection and the amount of skull augmentation possible is controlled by how much the scalp can stretch to accommodate it.

3) Custom skull implants provide a ‘bump it’ effect for females.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2018

The Effects of Botox Injections on the Jaw Angle Tissues

 

Botox is a well known neuromuscular modulating agent that produces a temporary muscle relaxation effect. It is mostly known for its positive aesthetic benefits in decreasing wrinkles in the forehead and around the eyes due to its effect on the muscles of facial expression. While the facial muscles may have a diminished action, the effect is temporary and is due to blocked axonal transmission across the neuromuscular synapses.

Botox is also effective on decreasing the size of masticatory muscles such as the masster and temporalis muscles. In this case the blocked synapses doe not necessarily decrease  muscle motion but cause a temporal atrophic effect where the muscle actually decreases in size. This effect has served as the basis for an injectable method to decrease the size of prominent masseter muscles and a wide lower face, most commonly used in Asian patients.

It has been postulated that this lower facial thinning effect is also due to a decreased thickness of the overlying fatty tissue as well as a decrease in the muscle’s thickness.

In the February 2018 issue of the Aesthetic Surgery Journal an article was published entitled ‘Does Botulinum Toxin Injection into Masseter Muscles Affect Subcutaneous Thickness?’ In this study the authors used ultrasonography to measure any changes in the muscle thickness as well as that of the overlying subcutaneous fat layers twenty patients. They divide into two groups of 10 who received either 25 units of Botox into each masseter muscle or a control group of saline injections. The tissue thicknesses were taken at one, two and three months after the injections. The subcutaneous thickness did not differ significantly over time either at rest or during muscle contraction or between the Botox-injected or saline-injected control groups at rest or during muscle contraction. This was in contrast to muscle thickness which did decrease significantly compared to the saline treated patients.

The effect of Botox injections into the masseter muscles is, perhaps unsurprisingly, a change in the size of the muscle. This decreased muscular size does not induce a concomitant overlying loss of fat. There does not appear to be any immediate trophic effect of muscle size and activity  on the fat that lies over it.

Dr. Barry Eppley

Indianapolis, Indiana

February 9th, 2018

Case Study – Geometric Broken Line Scar Revision of Complex Facial Scars

Background: Scar revision is an inherent part of plastic surgery and is one of its most recognized and historic procedures. While scars occur all over the body, those on the face are the most frequently and successfully improved by various scar revision techniques. While there is a role for the more simpler linear excision and closure of facial scars, more frequently the concept of changing a more linear scar line into a non-linear one is used. This is seen as more effective at both an improved scar appearance and less recurrence of scar widening.

The reason for breaking up a facial scar into a non-linear pattern is based on two fundamental concepts. A linear scar line that runs askew from the relaxed skin tension lines on the face is better hidden when it has an irregular pattern, making the scar harder for the eye to follow. Secondly by having the edges of the scar line interdigitate in an irregular pattern throughout its length the forces of wound contraction are better dispersed through greater surface area contact than having a straight line. This results in a decreased chance of scar widening.

The most common techniques for changing an adverse linear facial scar are based on various geometries such as Z-plasties, running W-plasties and the geometric broken line scar revision. Each of these has a role to play in scar revision and they do not all apply to every facial scar. The geometric broken line scar revision technique is the most common that I use because it offers the greatest disruption of any scar line and this the greatest amount of camouflage.

Case Study: This male had a history of a facial scars from a knife injury from years before which developed some wide scarring. These scars were all the more visible because of their lighter color on skin of a darker pigment.

Under general anesthesia a geometric broken one closure pattern was marked out using preformed plastic templates. These plastic templates ensure a good matching of both sides of the scar excision and can be repeated with longer scars. Then using deeper dermal sutures and small removeable skin sutures the edges of the excised. skin were put together to create the irregular closure line.

The initial facial scar revision already shows a significant improvement if for no other reason than the wide white scar had been removed.  It remains to be seen if secondary scar widening occurs but this would be unlikely. It will take up to 6 months after the procedure to appreciate the final scar appearance.

Highlights:

1) Severe linear facial scars are best improved by a geometric broken line scar revision technique.

2) The geometry of the scar revision closure pattern is not as important as that there is one for both improved camouflage and less tension on the closure.

3) Geometric broken line closure improves a scar’s appearance but it can not make it completely invisible.

Dr. Barry Eppley

Indianapolis, Indiana

February 9th, 2018

Technical Strategies – Perioral Mound Microliposuction

 

Defatting of the face is very different than the body. Due to the location of vital motor nerves, the more fibrous nature of facial fat and its very discrete locations, facial fatting is much more limited. While it is possible to selectively remove small areas of facial fat, it is not possible to have a more generalized and significant effect.

One such facial area that can be defatted is the perioral mound area. Often confused with the location of the buccal fat pad, this is a small collection of subcutaneous fat overlying the buccinator muscle just to the side of the mouth. It merges into the more inferior jowl fat which is also a subcutaneous fat layer. Patients often do not like the fullness that it creates in this facial area.

The perioral mound area can be treated by liposuction. Entering through a small incision just inside the corner of the mouth the area is easily accessed and treated. The key is that the traditional size liposuction cannula should not be used as it is too big. Even cannulas used for the neck can remove fat too much quickly or leave an irregular contour.

I prefer to perform perioral mound liposuction with a very small size cannula at the diameter of 1 to 1.5mm. The best cannula to use is actually not a liposuction aspiration cannula at all but a fat injection cannula. With just one hole on one side of the end of the cannula, it can be remarkably effective at removing fat from a small area like the perioral mounds with little to no risk of causing surface irregularities. This can be called therefore perioral mound microliposuction.

While the volume of fat extraction from the perioral mounds is small (1 to 3ccs per side) it can have a very visible reductive effect.

Dr. Barry Eppley

Indianapolis, Indiana

February 8th, 2018

Technical Strategies – Interpositional Grafting in Vertical Chin Lengthening Osteotomies

 

While much thought goes into the horizontal projection of the chin, and numerous chin augmentation procedures exist to change it, much less interest is in its other dimensions. One often overlooked deficiency of the chin is its vertical length. A short vertical chin is usually associated with a flatter mandibular plane angle where the horizontal position of the chin and jaw angle points are almost on the same line.

While some vertical chin deficiencies are part of  an overall underdeveloped chin (both vertical and horizontal shortness) some chins may have an isolated vertical deficiency. The chin may have enough forward projection but just looks short. This is usually very apparent when the classic vertical thirds of the face are considered.

Vertical lengthening of the chin as an isolated change can be done by an opening wedge bony genioplasty. Just like the osteotomy used in the classic sliding genioplasty the same intraoral bone cut is made. But instead of moving the bone forward, the front edge of the bone is dropped downward. With the back wings of the inferior bone segment staying in contact with the bony jawline, the front part of the chin is vertically lengthened by the size of the opening wedge. (bony gap) This gap and the vertical chin lengthening it creates is maintained by plate and screw fixation.

This opening wedge of the chin creates a bony gap. If this bone defect is not too big, bone will naturally fill it in over a period of up to six months after surgery. The exact size of a horizontal bone gap in the chin that can heal on its own is not precisely known. But the general rule that I use is that I don’t graft this gap when it is less than 5 or 6mms. But when the gap is closer to 8 to 10mm it is of benefit to do so.

Interpositional grafting of an opening wedge genioplasty can be one by a variety of materials. The use of allogeneic or cadaveric blocks or granules is an effective. A large solid block placed in the center grafts the biggest part of the defect and the sides can be left alone to heal in on their own.

Vertical chin lengthening helps to put the face in better balance and fixes an uncommon chin deficiency that is best appreciated in the frontal view.

Dr. Barry Eppley

Indianapolis, Indiana

February 6th, 2018

Square Custom Jawline Implant Design Principles

 

The well defined jawline has become a desirable facial feature. Actually I do not think that a weaker or poorly defined jawline has ever been a desired facial trait. But with today’s aesthetic facial trends highlighted by strong social media exposure has brought this desirous lower facial shape into high focus. While most commonly pursued by men, it is not uncommonly requested by some women as well.

For many patients the only way to really change the shape of their jawline in a reliable manner is with a custom made jawline implant. With a wrap around shape and the ability to set its angles and dimensional thickness, it is no surprise that it can be very effective. In the right face, that is not overly round or has very thick tissues, a more angular or squared jawline shape can be obtained.

But the key in any jawline implant design is what should that shape be? While every person is different and there is no set shape that will work for everyone, there are some basic guidelines I have learned from doing hundreds of these implant designs. (and then seeing their actual effects after being implanted)

For a square jawline implant the first step is to set the angles. From the frontal view the chin should be squared off at the vertical line of the canines. The jaw angles should be squared off at the desired width as well as at the horizontal level of how one wants t set the new jaw angle projection position. (width only, primarily vertical or some combination thereof) This is the hardest angle point to set but one of the most important.

In the side view the jaw angle shape is determined. Here it is important to not make it too square. But doing so it runs the risks of having the back part of the angle end up behind where the masseter muscle can cover it. So it must not be 90 degrees but more open at 110 degrees of so.

The width of the jaw angle should not exceed a vertical line dropped down from the widest part of the zygomatic arch. As you don’t want the width of the lower face to exceed the midface. (unless that is the patient’s desired aesthetic goal)

With this as a general guideline for the jawline implant shape its dimensions (thicknesses) must be determined. For this there are no exact guidelines but the setting of the chin and jaw angle shapes and positions will serve as a good guide.

Despite the fact that wrap around jawline implants are custom designed, it is not an exact science nor is there any guarantee that the patient’s desired result will be obtained. But by following certain design guidelines the chance for a satisfactory jawline augmentation change is more likely.

Dr. Barry Eppley

Indianapolis, Indiana

February 5th, 2018

Case Study – Female Forehead Augmentation using Bone Cement

 

Background: The forehead occupies a large surface area of the face and the broadest uninterrupted facial contour. Between the brows bone and the frontal hairline, it is a vast expanse of skin that can only be judged by its size and overall shape. While its more superficial features undergo frequent aesthetic manipulations (Botox, injectable fillers and brow lifts), the bony shape of the forehead does not. This, however, does not mean it is not capable of being changed but it is more of a surgical endeavor to do so.

The shape of the forehead can be very gender specific as is well known in facial feminization surgery as well as facial masculinization surgery. Beyond the very gender specific feature of the more prominent male brow bones, the female forehead has a more vertical inclination as seen in the side view and a more rounded shape between the temporal lines on the sides of the forehead best seen in the oblique or superior-inferior views.

Female forehead reshaping to create a more pleasing shape often involves augmentation of the frontal bone in a shape specific manner. There are two surgical techniques to perform it using different materials and incisional approaches. The traditional technique involves the application of bone cements placed through a wide open exposure. Such exposure is needed because bone cements, regardless of their material composition, are applied in a putty-like fashion and then shaped and allowed to set. Such applications can not be disturbed by the pressure of a tight overlying scalp/forehead flap less significant contour deformities be created in the augmentation. Not to mention that getting the right forehead shape initially requires good visualization.

Case Study: This young female had a more recessed and triangular forehead shape with a slight backward vertical inclination.

Under general anesthesia and through a full coronal scalp incision, the forehead was exposed down to the brow bones. Using hydroxyapatite bone cement the forehead was  built up with emphasis on increasing projection between the temporal lines and giving the forehead a rounder shape with more vertical inclination.

These forehead augmentation efforts created a rounder more convex shape that did not increase any brow bone projection.

Hydroxyapatite is one option for a forehead augmentation material. One could argue it is the ideal forehead augmentation as its inorganic hydroxyapatite crystals allows direct bone bonding to it. But because of how it is applied and shaped it requires a full coronal incision to use it properly. In addition at a material cost of $100/gram, and a typical case may require at least 50 to 75 grams, adds considerably to the overall expense of the surgery.

Highlights:

1) The shape of the female forehead is one of greater convexity and a more round shape when viewed from above or below.

2) One method of forehead augmentation is the use of bone cements done through a full coronal scalp incision.

3) Augmenting the lateral or temporal sides of the forehead, with or without increased central projection, creates a more vertically inclined shape that is rounder.

Dr. Barry Eppley

Indianapolis, Indiana

February 4th, 2018

Case Study – Breast Augmentation in Pseudoptosis

 

Background: Since breast augmentation is about increasing breast size it is no surprise that so much thought goes into choosing implant size before surgery. This is the one single issue that patients focus on and are often indecisive about before the surgery. No patient wants to be too big or too small knowing that in the vast selection of breast implant sizes there is the right one for them.

Numerous methods of breast implant sizing have been used and each has their own merits. The one I prefer is the volumetric method using different overlay sizers so the patient can see how different implant volumes affect their breast size. While not a perfect method it has worked as wells anything I have ever used and I have yet to have a patient sho felt their implants were too big with this sizing method.

Between breast base diameter and volumetric sizers, these parameters will work well for most patients. The other breast variable that must be considered is the overlying skin envelope. The volumetric sizers assume the breast skin is tight but when it is loose or has a deflated appearance it is going to take more implant volume to achieve what the volumetric sizers show.

Case Study: This 30 year-old female presented for breast augmentation surgery having lost much of her breast volume from having children. Her nipples were above the inframammary fold but there was some loose skin hanging over it. (pseudoptosis) Volumetric sizers showed she like 350cc implant size.

Under general anesthesia and through inframammary incisions, 425cc moderate plus profile silicone breast implants were placed in a dual plane location.

It is important to remember that the amount of loose skin on the breast will take more volume to expand outward than one may think and should be considered in the implant size selection process. The loose skin has lost elasticity and often has stretch marks. It will take more implant volume to fill it than if the overlying skin were tighter and there was less of it.

Highlights:

1) The amount of loose breast skin does influence how much implant volume is needed to fill it.

2) While there is no exact formula to calculate how much extra implant volume is needed to fill the ‘extra space’, it is best to add 50 to75cc onto the original breast implant sizing estimate.

3) It is best to overfill and not underfill the breast with loose skin when it comes to implant size.

Dr. Barry Eppley

Indianapolis, Indiana

February 4th, 2018

Clinic Snapshots – Large Skull Implant for Flat Back of the Head

 

Of all aesthetic skull reshaping surgeries in adults, correction of the flat back of the head is the most common. It is a skull shape deformation that is shared equally by women and men as well as crosses all ethnicities. It can be a complete flattening across the back of the heador it can be an asymmetric occipital flattening from plagiocephaly.

Computer designing of skull implants is the most effective method of head shape augmentation. I would only consider today the use of bone cements by patient request and can see no advantage with their use. Designing before surgery the exact shape and location that is needed far exceeds the surgeon’s ability to hand craft a remotely similar result using bone cements. This is particularly poignant when the amount or size of the skull augmentation would place a lot of stretch on the overlying scalp.

The amount of skull augmentation that can be done on the flat back of the head is partially dependent on the amount that the scalp can stretch over it. When this becomes a limiting factor a first stage scalp expansion can be done using a tissue expander. With this two stage approach up to 25mms of central occipital augmentation can be achieved. This number may not sound like much util you consider the entire surface area of the back of head covered by such an implant that was around its sides.

Age is not a limiting factor in skull augmentation as illustrated in this 70 year-old man who underwent a two-stage approach to augment the flat back of his head that had bothered him his whole life. Two surgeries separated by 6 weeks apart were able to achieve this result in the very tight scalp on the back of the head that had congenitally lacked bony projection.

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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