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.

December 4th, 2017

OR Snapshots – ePTFE Premaxillary-Paranasal Implant


Increasing the projection of the central midface at the base of the nose and upper lip involves augmenting the bony perimeter of the pyriform aperture. This anterior bony opening in the maxilla leads into the nose. At its more narrow end superiorly are the nasal bones. At its larger lower end the bone curves down and inward and meets in the middle to create the anterior nasal spine.

From an implant augmentation standpoint the pyriform aperture region has two distinct zones, the lateral paired paranasal regions and the central premaxillary region over the anterior nasal spine. The paranasal region has a flat or slightly concave surface while the premaxillary region is distinctly convex with a more V-shape projection to it. These anatomic central middle regions can be a augmented by three different styles of implants, paranasal, premaxillary and a combined premaxillary-paranasal implant.

Because of the tree different zones of potential augmentation and the very limited implant styles available, this is a very confusing area for surgeons and patients alike. The only preformed facial implant available is the peri-pyriform silicone implant. By its name and shape it is a premaxillary-paranasal implant since it covers all three zones. But it can be sectioned in the middle and turned into just paranasal implants if desired.

Another option to make a complete premaxillary-paranasal implant is to carve it out of an ePTFE block. Shaped almost like a moustache, the adaptability of this material allows it to be molded into placed over the central projecting spine and around the more concave sides into the maxilla. It may look large when positioned on the outside of the patient but it needs a lot of material to properly cover this central midface area.

The premaxillary-paranasal implant is placed through an intraoral incision under the upper lip. The key is to make the incision high enough on the lip side of the vestibule to maintain a good musculomucosavl cuff of tissue to close over the implant with a two layers of suture.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

Does Large Volume Liposuction Have Medical Benefits?


Liposuction is a well known subcutaneous fat removing technique that has proven to be very effective. It can be so effective that large volume liposuction became commonly practiced until its potential adverse effects and complication rates came to light and safe amounts of maximum removal became established. (5 liters) While not a weight loss technique, removal of large fat amounts does raise the question of whether it may have medical benefits as well. Since fat is a very metabolically active tissue does its reduction have any positive benefits on metabolic and cardiovascular health.

In the December 2017 issue of the Annals of Plastic Surgery an article was published entitled ‘Influence of Large-Volume Liposuction on Metabolic and Cardiovascular Health: A Systematic Review’. In this review paper the authors looked at published reports of studies where large volume liposuction was performed (as defined as greater than 3.5 liters) as well as patient’s cardiovascular risk factors, inflammatory cytokines and insulin resistance/sensitivity measured. Twelve (12) studies were identified that were prospectively conducted. A total of over 350 patients were included in these studies of which the mean body mass was around 30. The mean volume of fat removed was over 7 liters. Seven of the studies showed a decrease in total cholesterol levels with an overall mean reduction of 0.2  mmol/L from 4.6 to 4.4 mmol/L. Leptin was shown to significantly decrease in 4 studies, and TNF-? was reported to be lower in  two studies. Adiponectin was show to significantly increase in two studies. IL-6 in two studies. Most of the studies evaluated insulin sensitivity, two included patients with type II diabetes. Six of the ten studies reported improvement in insulin sensitivity.

Ultimately the question being posed/studied is whether liposuction improves one’s health? Does removing a large volume of fat in a very short period of time have medical benefits? It is tempting to think (hope) so. But the evidence to support that contention is tenuous at best. Some of these studies offer conflicting data or positive changes that are relatively small. Certainly an immediate reduction in one’s fat volume would improve some of the metabolic markers studied. But whether those changes lead to a lower risk of cardiovascular disease or the need for less insulin in diabetics remains to be definitively proven. These potential benefits must be weighed against the risks of surgery which are increased in these larger volume liposuction patients.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

Case Study – Transaxillary Saline Breast Augmentation


Background: Breast augmentation can be done using two different types of implants, saline and silicone.  (technically three if you include the saline-filled Ideal implant) Both type of breast implant has their own unique advantage sand disadvantages Silicone offers the most natural feel and an implant that will probably last longer as it can not undergo a spontaneous deflation. But these benefits come at a higher cost of the implant.

Saline breast implants have as their main advantage that they are the most economical of all breast implants. They also can be inserted with the smallest incision as they are deflated and rolled to pass through the skin entrance site and then are subsequently inflated to the desired volume size. Such characteristics make them appealing to many younger women who may be more financially challenged and are often the most concerned about incisional scars.

Case Study: This 19 year-old female wanted saline breast augmentation. Her mother and her two sisters had prior breast augmentation over ten years ago with saline implants and have never had a problem yet.

Under general anesthesia through a 2.5 cm transaxillary incision, 200cc saline implants with 11.5 cm base diameter were placed in the submuscular position and inflated to 250ccs. This was done in a non-endoscopic fashion.

Her early two week result showed good symmetric implant placement and incisions that already looked good as this early point. In a few months these scars will fade and will probably be very hard to find.

While breast implants and the surgical technique to place them continue to evolve, the ‘old’ transaxillary saline breast augmentation technique continues to produce successful results for the patient who is willing to accept a saline-filled implant.


1) Saline breast implants remain popular particularly amongst young women.

2) The deflated and rolled insertion method for saline implants allows them to be placed through the smallest possible incision.

3) The transxillary incision for saline implants still remains a preferred method for their placement.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

Technical Strategies – Vertical Chin Cleft Creation with Chin Implant Augmentation


The chin has few topographic features on an otherwise round convex shape as it covers the projecting chin bone. Chins can have either a dimple or cleft. A chin dimple is a circular central indentation of the soft tissue chin pad. A chin cleft is a vertical indentation through the lower half of the chin pad that extends to the inferior border. While many perceive that these chin indentations are caused by the bone underneath them (particularly a vertical cleft), they are actually anomalies in the soft tissue and not the bone.

The vertical chin cleft is the easiest to understand since the lower jaw is formed by the paired brachial arches that meet in the middle in the embryo. Failure to have a complete meeting in the middle can result in a ‘cleft’ of the overlying soft tissues. Or more likely the union of the tissues developed a very slight separation that resulted in a very minor soft tissue cleft.

When surgically trying to make a chin cleft, making a vertical defect in the bone alone will not work. Or in the case of placing a chin implant, a ‘cleft’ chin implant will also not create the desired effect. It requires soft tissue manipulation, preferably from a submental incision, to make an effective external cleft appearance.

When doing a combined chin implant and vertical cleft creation, the bigger the chin implant the more likely it will be effective. Whether the chin implant is round or square does not matter, it can be done equally well in either one. The key technical points are two-fold. First a wedge of cleft must be made through the center of the implant to create a channel for the soft tissue anchoring. In so doing the implant will need to be secured with screws on each side so it remains positionally stable. Secondly a vertical wedge of soft tissue (muscle and fat)is removed from its underside up to the dermis of the skin. Sutures can then be placed to pul the skin down into the implant cleft. This will create a resultant vertical indentation of the overlying external chin.

A vertical chin cleft can also be created in patients who are not undergoing chin implant augmentation. The technique is the same with the exception that a vertical groove is made into the lower edge of the bone as opposed to that of an implant.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

Technical Strategies – Subcostal Rib Shaving


Most of the ribs are near circumferential bone and cartilage ‘fingers’ that provide shape to the chest and abdomen. Some of these ribs can be modified to improve the shape of the torso. In the upper abdominal region is the subcostal portion of the ribcage which is composed of the union of ribs #7 through 10 of its lower portion. This creates an arc of cartilage that is shaped like a stretch out ‘U’.

Normally the subcostal ribcage has a slightly more horizontal projection than the rest of the ribcage above it. But it can have an increased projection due to genetics, congenital deformities or injury. This can create a protrusion of the subcostal ribcage that creates an unaesthetic flare or prominence.

Reduction of subcostal rib protrusions must usually be done through a direct incisional approach to be maximally effective. I have used a tummy tuck approach which can be done if the patient needs a concomitant tummy tuck. I have also approached the subcostal ribs through an inframammary incision but this does not provide good access for optimal rib reduction. The direct incision allows the rectus muscle to be vertically split and the ribs easily exposed.

Unlike posterior rib removal (#s 10, 11 and 12) where the removed ribs are done in a full thickness manner, subcostal rib modifications are often done in a reduction technique and not a removal technique per se. The protrusions can be reduced by a subcostal rib shaving technique. This can be done with a scalpel for the softer cartilaginous portions and a high-speed handpiece and burr for the more ossified cartilage portions or actual bone. The ribs can be shaved down to where there is only a thin layer left protecting the intercostal neurovascular bundle and the pleura underneath should it be located this low on the ribcage.

Subcostal rib shaving also prevents blunt ends of the remaining rib from being seen on the outside should a total resection be done. This is of particular relevance in thinner patients where there is little soft tissue cover. Rib shaving ensures that there remains a smooth shape to the reduced subcostal protrusion. Shaving may seem like it does not remove much rib but when the pieces are put together the amount of rib removed looks more substantial.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

The Role of Mandibular Ligaments in Chin Implant Surgery


Chin augmentation using an implant is the common form of aesthetic facial augmentation. Putting an implant on the front edge of the chin bone has been done for over fifty years using a variety of materials. Silicone chin implants dominate the materials used for chin augmentation and are available in a variety of styles. The extended chin implants, or an implant style that has long wings that go back along the sides of the chin into the jawline, is the basic concept of most chin implant designs today.

While chin implants are effective for increasing the horizontal projection of the chin, they are not complication free. The most common adverse aesthetic issue with their use is malposition. With the extended implant design the risk of such malpositions are magnified as it doesn’t take much less than a perfect horizontal leveling of the implant to have wing asymmetry.

The longer wings of extended chin implants requires that a complete subperiosteal elevation of the tissues is done along the lower edge of the chin. If the tissues are not adequately released the wing of the implant will to be allowed to extend back as it was designed. Because the wing of these implants is very thin it is quite easy for their tips to bend with little detention that it has happened.

In executing the subperiosteal dissection along the inferolateral rim of the chin and anterior jawline, firm attachments are always encountered. These are the key anatomic structures that must be released for good pocket creation. These ligaments are the mental ligament and has been described as occurring about 1 cm to the midline and just superior to the inferior border of the mandible. Further back is the medial mandibular ligament located about 3 cms from the midline. (I prefer to call this the Ligament of Binder by the surgeon who first described its significance in surgically placing chin implants) A third mandibular osteocutaneous ligament also located about 5 cms to the midline and his has greater relevance in custom chin and jawline implants which go much further back along the jawline.

The release of these mandibular ligaments is the key in chin implant placement regardless of whether it is done through a submental or intraoral approach. Failure to do can result in chin implant malposition and external asymmetries.

Dr. Barry Eppley

Indianapolis, Indiana

December 3rd, 2017

Case Study – The Triple Roll Tummy Tuck with Pubic Lift


Background: Large amounts of weight loss cause an expected amount of abdominal skin looseness and overhang. The deflation of the abdominal and waistline fat causes a resultant skin excess that hands down. This most commonly results in a single roll of tissue that hangs over the waistline known as an abdominal pannus. In patients with a lot of remaining intra-addominal fat or a thick upper abdominal subcutaneous fat layer, the deletion of weight loss causes a tissue roll above the umbilicus as well as below it. (double roll abdominal deformity)

But a third roll in weight loss patients is also possible but it does not involve the abdomen per se. If one has a large pubic region initially it will partially deflate and sag. This smaller tissue roll is pushed down by the larger tissue roll above it, creating the third roll or the triple roll abdominal deformity.

A large and low hanging pubic ‘pannus’ complicates the tummy tuck design for these larger excisional patients. Should the central part of the lower tummy tuck incision go lower to remove the upper third of the sagging pubic mound or should the tummy tuck markings be done in the standard fashion above the pubic mound and just do liposuction of the pubic mound to further deflate it? Or should some combination of both pubic mound management strategies be done?

Case Study: This 45 year-old female lost over 60lbs on her own but developed the triple roll abdominal deformity. She has a large and full pubic mound that hung down between her inner thighs.

Under general anesthesia she underwent a tummy tuck that included excision of the complete middle abdominal roll, a portion the lower end of the upper abdominal roll and the upper third of the pubic mound or lower pubic roll. Her postoperative result shows substantial improvement although not completely flattening of the entire front torso.

The pubic mound shows a significant lift but not a complete flattening of its profile. The abdominal wall above it is also much better but is similarly not flat. Ideally a second stage procedure is needed primarily focusing on liposuction of the abdomen and pubic mound for further flattening. Some additional skin above and below the tummy tuck scar may also be needed.

The triple roll abdominal deformity is a difficult problem to ideally correct in a one-stage procedure. It often takes a second procedure to improve the results of the first tummy tuck with additional fat and skin removal.


1) The ‘triple roll’ abdominal deformity can happen after a lot of weight loss in certain women.

2) The third roll in this type of abdominal lipodystrophy is the pubic ‘pannus’.

3) The low hanging and full pubic pannus must be factored into the design of the tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

November 30th, 2017

Case Study – Custom Pectoral Implants Replacements


Background: The equivalent to female breast augmentation in men are pectoral implants. Besides the obvious differences in aesthetic objectives, pectoral implants differ in that they are solid devices that are placed completely in a submuscular position within the confines of the borders of the pectoralis major muscle. This is almost always done through a transaxillary incisional approach.

Like breast implants, pectoral implants can develop the same complications such as implant malposition and size and shape concerns. Choosing the correct pectoral implant style and size is an art form that belies an exact science to it. Most men today want a chest that has a more rectangular shape that adds visible fullness to the sternal border of the muscle as well in the superomedial pole of the chest. Implant projections range from more modest amounts of 2 cms or so up to 3.5 to 4cm.

One indication for pectoral implants is in cases of corrected precuts excavatum. Even in near optimal corrections the chest is often flat and lacks visible muscle definition. The muscle is often underdeveloped and may have a smaller shape due to an aberrant origin along the sternum/ribcage. The use of pectoral implants in asymmetric chests have a high risk of malpositions and magnifying such pre-existing chest asymmetries.

Case Study: This male patient had previously undergone a Nuss procedure for correction of his precuts excavated. This left lateral chest wall scars. He then had pectoral implants placed through these same scars but developed asymmetry in the appearance of is chest. he was uncertain about the exact shape and size of his pectoral implants. A 3D CT scan showed that the right pectoral implant was rotated 90 degrees and was sitting lower as it extended beyond the lateral pectoral muscle border.

In considering his pectoral implant replacements, custom implants were designed that had a better shape for his chest but with a similar projection to his indwelling implants.

Under general anesthesia his existing pectoral implants were removed through the lateral chest wall incisions. Both implant pockets had a fluid collection which was greater on the right than the left. The removed implants could be seen to have been modified on their underside and the right implant had tears in two locations. The pockets were cleaned and irrigated and the new implants placed. The lateral border of the right pectoral muscle was re-established/tightened using permanent sutures to the ribcage.

This case represents two observations. First, while all solid body implants can be altered, doing so removes the outer shell of the implant exposing the tissues to the sifter inner gel. This can be a potential source for irritation and the development of chronic serums. When possible it is best to not cut into preformed solid body implants. Secondly, custom pectoral implants are ideal when treating chest wall asymmetries that have either been previously implanted or are being treatment planned for the first time.


1) Asymmetry in pectoral implants can be the result of implant positioning or differences in the natural chest anatomy.

2) When in doubt about pectoral implant positioning and style/size, a 3D chest CT scan can help identify the problem.

3) Custom pectoral implants can be an effective solution to chest asymmetry after implant augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

November 29th, 2017

OR Snapshots – Hourglass Figure Surgery


Altering the shape of a woman’s body has been a part of plastic surgery for over fifty years. This has traditionally meant such procedures as breast augmentation, liposuction and tummy tucks. In the most contemporary forms of female body contouring the role of the buttocks and hips, once deemed undesirable, have become popular. This has added buttock and hip augmentation using either fat transfer and implants to the options available for body reshaping.

The hourglass figure shape is one in which there is larger breasts, a narrow waist and hip widths similar to that of the breasts. In its most extreme form it has an appearance to that of an actual hourglass with a wide upper and lower half and being narrow in circumference between the two halves. Some deem such a female body shape as more desirable than others. Between the options available in plastic surgery and the use of traditional corsets the hourglass shape today is more attainable than it has ever been.

One newer addition in hourglass figure surgery in is that of rib removal. Reductions in the lengths of ribs #10, 1 and 12 removes the last rigid anatomic restriction to maximal horizontal waistline reduction. This procedure is only appropriate when the more traditional use of liposuction has already been done to reduce any fat collections around the waistline. When combined with other body contouring procedures such as buttock augmentation (in this picture with buttock implants), the hourglass figure may become a reality.

Hourglass figure surgery has numerous options to both augment the upper and lower half as well as narrow what lies in the middle. Larger breast implants, custom buttock implant designs and rib removal represent options for those women that seek a maximal approach to altering their body into more of the hourglass shape..

Dr. Barry Eppley

Indianapolis, Indiana

November 29th, 2017

OR Snapshots – The Safe Limit of Fat Removal in Liposuction


Liposuction is the most commonly performed cosmetic body contouring procedure, both by number of patients and body surface area. It has undergone a lot of technical improvements over the past third-five years from patient indications to the technical equipment needed to perform it.

While understandably viewed as an aesthetic procedure, its traumatic impact on the body is often overlooked. The small skin entrances for the introduction of the fat-sucking cannulas belies the generalized injury to the subcutaneous tissues which has been treated. The trauma to the fatty tissues and all that runs through it is considerable. Any patient that has had the procedure can testify that its recovery is usually greater than they could have anticipated both in terms of swelling and bruising and the time it takes for its resolution.

The trauma to the body and how it responds to it has been well appreciated with the most extreme form of it in large volume liposuction. This term has become known as any amount of fat removal that exceeds five (5) liters. When fat is removed in a singe setting at greater than this volume, the effects on the body result in fluid shifts and blood loss that can result in potentially major complications. At the least it prolongs the recovery time and can take more than month after surgery for the patient to feel more normal again. Numerous adverse outcomes from the 1990s, when large volume liposuction became popular, proved that whether it can be done should be preceded by whether it would be done.

If one wants a large amount of fat removed it should be done in stages given that liposuction is an elective procedure.  While the five liter limit is not an absolute, as it should really be based on body weight or even body surface area, it does serve as a good clinical guideline.

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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