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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.

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

September 24th, 2017

OR Snapshots – ePTFE Implant Framework in Ear Reconstruction

 

Reconstruction of the lost ear requires a two-layer approach. The base la\yer is the firm and shaped framework which replaces the missing natural cartilage. The choices for the framework are either rib cartilage or synthetic framework.  The second layer is the need for vascularized tissue coverage which, in cases of large amounts of ear loss, would be a temporoparietal fascial flap and a skin graft.

While there are debates about the merits of a cartilage or an implant base layer, the one huge advantage that a synthetic framework has is the avoidance of a donor site. Historically the biomaterial porous polyethylene its what has been used for synthetic ear reconstruction frameworks. It has the advantage of surface porosity and good soft tissue adherence. But it is a difficult material to shape and assemble its preformed pieces. It is also a very stiff and inflexible material of which natural ear cartilage is not.

An innovation in ear reconstruction implants is the combination of 3D design/printing and the use of a softer implant material. In unilateral ear loss or deformities a 3D CT scan can be used to make an exact replica of the opposite normal ear cartilage. Usually this will include the soft tissue earlobe as well as that is difficult to surgically create. From this auto design an implant can be fabricated. This its then made from a newer material, a solid silicone base covered with an ePTFE coating. The silicone provides the shape and flexibility that more closely resembles ear cartilage and the ePTFE coating allows for soft tissue adherence.

An ear framework that is computer generated saves operative time and ensures the best potential ear shape result. It still needs to be covered by a vascularized soft tissue layer. But that need is necessary regardless of the material composition of the ear framework. 

Dr. Barry Eppley

Indianapolis, Indiana

September 23rd, 2017

Case Study – Temporal Skull Reconstruction with Hydroxyapatite Cement

 

Background: Access to the brain and its lining requires the removal of part of he skull. Known as a craniotomy flap, the bone is usually removed in he shape of a semicircle or a full circle. Once the intracranial work is complete the bone flap is put back into place. But because the bone edges are vertical and a thin rim of bone at its perimeter has been removed in its creation, such bone flaps are well known to fall in or sink down creating an external bone contour deformity of the skull.

To avoid craniotomy flap sinking, plate and screw fixation is commonly used. A variety of differently shaped plates have been developed to rigidly hold the bone flap up as it heals. But despite such metal fixation, not all bone flaps always stay up as much as desired usually due to the failure of good bone healing across the surrounding bone flaps.

Treatment of a depressed craniotomy bone flap can be done by two fundamental approaches…either reposition the bone flap or leave it in place and contour on top of it. Both methods can be effective but employ very different technologies to perform.

Case Study: This middle-aged male had a left temporal craniotomy performed due to a traumatic injury and the need for treatment of a subdural bleed. Six months after the procedure, he had a very noticeable temporal depression that made him look like a piece of his head was missing from certain angles. The anatomy of his temporal depression was more than just the sinking of the bone flap, it was also due to the atrophy of the temporalis muscle as well.

Under general anesthesia the depressed bone flap was exposed through his original scalp incisions. It could be seen to be sunken in despite the use of plates and screws. The depressed bone flap had some mobility so a more rigid floor won top of the bone was created using a very shapeable hexagonal mesh material. On top of the mesh layers of hydroxyapatite cement was used to build up the bone contour including some compensation of the loss of muscle as well.

His after surgery results showed a much improved temporal and head shape contour. Because if the contouring capability of hydroxyapatite cement, one could argue that it is a superior approach than trying to reposition the bone flap in skull reconstruction particularly in the temporal region where muscle adds to its natural contour..

Highlights:

  1. Temporal craniotomy bone flaps can become depressed despite rigid fixation.
  2. One approach to craniotomy flap reconstruction is to leave the depressed bone flap in placed and build out the contour to the level of the surrounding bone.
  3. The combination of hydroxyapatite cement and a mesh floor  can be used to augment a depressed craniotomy bone flap.

Dr. Barry Eppley

Indianapolis, Indiana

September 23rd, 2017

Case Study – Extra Large Custom Testicle Implants in Penile-Scrotal Disproportion

 

Background: Testicle implants are an accepted and low risk device that can effectively create the appearance of a testicle in the scrotal sac. Available in saline-filled and solid silicone styles, their effectiveness is judged by having an adequate size and feeling soft and slightly compressible. Because of larger sizes and a softer feel to the implant, the solid silicone device would be judged to be superior in the scrotal location.

IIn testicular restoration one the most important criteria is size of the implant. While solid silicone implants are available in five different sizes, up to 5cms in linear length or 5.5vm in arched length, there are men where even larger implants are needed. Such implants can be made on a custom basis to dimensions that are only limited by the stretch of the scrotal skin.

The need for extra large testicle implants is most commonly needed in aesthetic penile-scrotal disproportion. This can be created by penile enhancement procedures where the length and girth of the penis becomes bigger and disproportionate to the natural underlying scrotum. While there are no established measurements or numbers to determine the aesthetic proportionate relationship between penile and scrotal size, patient perception of it becomes the determining factor. 

Case Study: This middle-age male had a history of  having both penile enhancement (fat injections and a pump) and saline testicle implants. He was bothered by the relatively small size of his testicle compared to that of his penis. To meet his aesthetic implant replacement size, custom testicle implants were made with a linear dimension of 6 cms ands and arced length of 6.5 cms.

Under general anesthesia a median raphe incision was used to access both sides of the scrotum. A thick layer of  tissue was maintained in the middle. The saline implant pockets were opened and the devices were removed including their fixation sutures. The capsule was released in many linear lines and the scrotal pockets stretched and expanded.  The old saline implants were compared to the new implants. The new custom silicone testicle implants were then inserted and a three layer closure done. A semi-circumferential ring of skin was removed from the base of the penis to get rid of a ‘turkey neck’. (loose skin)

The need for custom silicone testicle implants is indicated when standard sizes are inadequate. Penile enhancements can create penile scrotal disproportions where such larger implants may be needed.

Highlights:

  1. Large testicle implants are only available in silicone and must be custom made.
  2. The scrotal tissue pocket can be released by capsulotomies and skin stretching to accommodate much larger implants.
  3. Custom testicle implants may be needed when their is significant aesthetic penile-scrotal disproportion.

Dr. Barry Eppley

Indianapolis, Indiana

September 22nd, 2017

Pocket Location for Hip Implants

 

The newest member of the body implant family is that of hip implants. Augmentation of the lower torso has been done by various styles of buttock implants for decades. While the majority of buttock augmentation today is done by fat injections (aka Brazilian butt lift), there has been a relative neglect of the hips to the side of the buttocks due to either a lack of adequate fat to inject them or poor fat graft take over the often concave and tighter tissues of the  trochanteric hip region.

From an anatomic standpoint, the hip augmentation zone extends from below the superior iliac crest  down over the trochanteric tuberosity of the femur bone. Underneath the skin and fat layers lies the tensor fascia late muscle/fascia (TFL) which attaches to the iliac crest and runs continuous with the iliotibial band (ITB) down to the side of the knee where it attaches to the lateral epicondyle. At its superior extent the TFL combines with the posterior ITB to create the upper half of the hip fascia. Posteriorly this thick fascia connects to the gluteus maximus muscle creating an overall continuous sheet. Underneath the ITB inferiorly is the vastus laterals muscle. The function of the TFL is for hip movement specifically abduction, flexion and internal rotation.

When considering alloplastic hip augmentation one has to decide whether it is to be placed above or below the TFL. This is primarily determined by the size of the implant and the desired dimensions of hip augmentation. Subfascial placement of the implant is more restrictive in size and will have some short term functional issues. (short term side of the knee discomfort due to the ITB attachment It is somewhat analogous to intramuscular buttock implants where the size of the implant is also restricted and it will induce temporary limited range of motion. When the hip augmentation needs are not excessive a subfascial pocket location can be effective and falls into the general implant philosophy that the tissue coverage an implant has the better.

On top of the  fascia or a deep subcutaneous pocket location in hip augmentation offers the opportunity for larger implants both in perimeter surface area of coverage but also in thickness. Having placed numerous such hip implants I have observed that the thickness of the implant is less important than how much surface area it covers. Greater surface area coverage also allows for a smoother transition into the surrounding buttock and thigh contours. Broader hip implants also requires that their softness (durometer) be the lowest possible so they do not feel restrictive in any way.

Hip augmentation can be successfully done using implants. Currently there are no standard sizes or styles of these body implants. Currently I make all such implants are a custom basis based on patient measurements of surface area coverage.

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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