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 12th, 2017

Case Study – Scrotal Reduction

 

Background: The normally quiescent scrotum that draws little attention can become a major focus when it dramatically enlarges. There are a variety of causes for scrotal enlargement including injury, genital and pubic mound surgery, inguinal hernias,  testicular torsion, varicoele, orchitis, hydrocoele and epididymitis to name the most common. In almost of of these causes once the source is properly treated and healing has occurred the scrotum will shrink back to normal. Acute scrotal edema almost always completely resolves.

Chronic scrotal edema/enlargement occurs from different sources. One of the common for refractory scrotal enlargement is lymphedema. If partial blockage occurs of the draining lymphatics or veins, the scrotum will remain edematous. There is no compression method to conservatively treat chronic scrotal lymphedema and make the scrotum smaller. Trying such compression may actually worsen the problem and may hinder the already limited blood supply to the scrotum. Further obstructing the venous outflow can increase the swelling. In addition the thin scrotal skin is not very tolerant of compression besides the obvious difficulty. Chronic scrotal enlargement can only be reduced by surgery.

Case Study: This 32 year-old male presented with chronic scrotal enlargement, being roughly 2X to 3X its normal size. He had a history of some form of autoimmune skin infection of the groin, believed to be a form of psoriasis. It eventually become improved through the use Humira and daily low-dose antibiotics. While not 100% cured, it was 98% improved. This skin condition left him with a chronically enlarged scrotum with thickened skin and diffuse subcutaneous tissue thickening. Besides its appearance, it gave him difficulty with wearing clothes and chaffing of the groin and scrotal skin.

testicular dissection in scrotal reduction Dr Barry Eppley IndianapolisScrotal Skin RemovalScrotal Reduction Surgery Dr Barry Eppley IndianapolisUnder general anesthesia and in a frog-legged position, a large elliptical excisional pattern was marked out vertically using the midline raphe as the center. The widest area of excision was 14 cms. The thickened skin and the watery expanded superficial fascial tissue were excised. The testicules and the enveloping tunica vaginalis lining were dissected out and preserved. Closure was done by covering the testicles with the remaining scrotal skin with a midline approximation.

A chronically enlarged scrotum can be effectively reduced by wide excision of the redundant tissues. The scar line should be placed along the naturally occurring midline raphe where a good scar outcome would be expected.

Highlights:

1) Permanent scrotal enlargement can occur from chronic skin infections that results in enlarged and abnormal skin

2) Scrotal reduction involves an elliptical excision of skin and fascia centered along the vertical midline raphe.

3) Scrotal reduction preserves the testicles and their surrounding sac.

Dr. Barry Eppley

Indianapolis, Indiana

February 12th, 2017

Case Study – Breast Implants and Stretch Marks

 

Background:  The finding of stretch marks on the breasts is common and reflects loss of skin elasticity from pregnancy and/or weight gain/loss. They always occur in a radiating pattern around the areola like rays of the sun. Careful inspection of the stretch marks will reveal that they are thinner than the surrounding skin and have less pigment. In many ways, they represent skin that has partially torn and is now a line of scar.

It is rare that breast implants ever cause stretch marks. It can happen, and it is an occurrence I have read about, but no a postperative breast augmentation finding that I have ever seen. Conversely, the other question is whether placing breast implants will make existing stretch marks look worse. Since so many women have them it is an understandable concern of will happen to them afterwards when the breasts become larger.

Case Study: This 32 year-old female came in for breast implants. She had lost most of her breast volume after multiple pregnancies. Despite the involution her nipples had good position above her inframammary folds. But she did have many wide and deep stretch marks radiating outward from her areola in a 360 degree pattern.

Breast Implants and Stretch Marks result front view Dr Barry Eppley IndianapolisUnder general anesthesia and through inframammary incisions , 325cc smooth round silicone breast implants were placed in a dual plane position. Her stretched out breast mound skin had no problem accommodating these modest size breast implants.

Breast Implants and Stretch marks result oblique view Dr Barry Eppley IndianapolisBreast Implants and Stretch Marks result side view Dr Barry Eppley IndianapolisHer breast appearance just a few weeks after surgery shows stretch marks that actually appear worse. Often times the immediate stretch of the tissues from the implants makes the scar hyperemic and the small capillaries in them dilate. This subsides over first couple months as the swelling goes down and the skin relaxes.

Highlights:

1) Having stretch marks on the breasts does not preclude one from having breast implants.

2) Breast augmentation surgery may temporarily make severe stretch marks look worse due to temporary redness.

3) Breast augmentation surgery, on average, does not appear to make stretch marks look better or worse in the long run.

Dr. Barry Eppley

Indianapolis, Indiana

February 12th, 2017

Vertical Lengthening Jaw Angle Implants

 

While jaw angle implants have been around for over 25 years, they only recently have become more popular and in higher demand for jawline enhancement. Offering augmentation to the often overlooked back part of the jaw, they add dimensions to the lower third of the face that can be primarily seen in front and oblique facial views. This is in contrast to chin implants which create their most profound effect in the side or profile view.

Based on how they impact the face it can be appreciated that the combination of chin and jaw angle implants creates a true 3D total jawline effect through a three-point triangulation effect.

Like many other facial implants, jaw angle implants also come in different styles. Fundamentally there are two different jaw angle implant types, widening (lateral) and vertical lengthening. This distinction is critical as they create profoundly different effects on the jawline.

The original and still commonly used jaw angle implant is the widening version. The implant sits on the outer aspect of the posterior-inferior ramus and gives the jaw angle more width. This is suitable in the patient who already has adequate length to their angles, has a normal mandibular plane angle and just needs augmentation to their natural bony width.

While appropriate for many patients, widening the jaw angle does not work well for everyone. An overlooked aesthetic jawline diagnosis is the patient who has high angles. They may also be too narrow but the jaw angle is almost at the level of the earlobe. This is too high of a mandibular plane angle and requires vertical lengthening. Placing widening angle implants in the high mandibular plane will just make the face look wider/fatter and will not create a more defined jaw angle appearance.

Vertical lengthening jaw angle implantsVertical Lengthening Jaw Angle Implants Dr Barry Eppley IndianapolisA newer style of vertical lengthening jaw angle implants has been developed for the high angled jawline. In this implant style a portion of the implant sits below the existing angle bone. By dropping down the angle it not only gives it more visible length but also adds width as well. These two dimensional changes put together into an angular shape creates a much more visible jaw angle and fullness to the back part of the jawline.

Most patients who have a short chin usually have a higher jaw angle position. This is a natural part of the L-shape to the lower jaw and the way it develops from its growth center. A chin implant with vertically lengthening jaw angle implants is the best combination for total jawline augmentation in these patients.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2017

Vertical Ear Reduction with Setback Otoplasty

 

The vertically long ear is one that appears disproportionate to other facial features. Generally if the length of the ear is greater than that of the nose, for example, it can be judged to be too long. But no matter how it is measured of the patient thinks the ear is too long then it is.

When performing a setback otoplasty for protruding ears, it is not rare to see that the ears are also vertically long. While sometimes this can be an illusion because of the ear’s degree of outward protrusion, measurements and trial reshaping of the ear can confirm if it is really too long. If this diagnosis is missed before surgery, the setback ear may look better but still be too long. In some cases of how setback otoplasty sutures are placed, it can even make the long ear look even longer.

In the Online First edition of the February 2017 European Journal of Plastic surgery an article was published entitled ‘Upper Third Ear Reduction with a Posterior Approach’. In this paper, the authors report a specific technique for the reduction of the upper third with a posterior approach based on resection of the scapha and remodeling of the posterior skin excess. This is an ear reshaping technique that is combined with setback otoplasty.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder normal circumstances it it virtually impossible to siginificantly reduce the vertical height of the ear without removing anterior ear skin and cartilage. The fear in doing so of course comes from concern about visible scarring. Despite these scar concerns it has not been a problem in my vertical ear reduction experience.

But when combining vertical ear reduction with a setback otoplasty, it is not wise to use the traditional anterior scaphal cartilage and skin resection technique. While it is not the cartilage resection that is the problem but the placement of incisions on both the front and backside of the ear. For this reason removing cartilage only from the posterior approach is done at the time of the setback otoplasty. Folding the ears back will allow the scaphal cartilage gap to close and shorten the height of the ear somewhat. Any skin excess can then also be removed.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2017

Case Study – Weight Loss Breast Augmentation

 

Background:  Significant weight loss, albeit through diet and exercise or bariatric surgery, will have a dramatic effect on all body areas. As the fat is burned off the support for the skin is lost. This causes an overall body sag that creates a well known collection of body changes that are most reflected centrally in the trunk.

For women one of the most affected areas is that of the breasts. The loss of breast volume allows the overlying skin to sag and the nipples to head south. What degree of breast sag that ensues depends on how large the breasts were initially and whether they had any significant sag before the weight loss. Smaller breasts develop less sag while larger breasts can have a dramatic sag with a large skin sleeve that ends up having them lay against the upper abdomen.

Breast implants are almost always needed for ‘reconstruction’ of the weight loss breast. Whether they can be effective by themselves without the need for a breast lift depends on how much skin sag exists.

Weight Loss Breast Augmentation Female before surgery Dr Barry Eppley IndianapolisCase Study: This 22 year-old female underwent a 60lb weight loss on her own without the need for bariatric surgery. The breasts must have been initially small ad the skin sag was slight and the nipples still remained fairly centralized on the reduced mound size.

Weight Loss Breast Augmentation result front view Dr Barry Eppley IndianapolisWeight Loss Breast Augmentation result right oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, a transaxillary approach was used to place 375cc saline breast implants that were filled bilaterally to 450ccs in the partial submuscular position. This filled out her breasts fully. Like many transaxillary breat augmentation approaches, the initial result will have slightly too much upper pole fullness which will settle over time.

Weight Loss Breast Augmentation result side view Dr Barry Eppley IndianapolisWith the nipples above the inframammary fold, breast implants is all that is needed in the large weight loss female. Unfortunately for many weight loss women the breast condition is not so favorable that implants alone will suffice.

Highlights:

1) Significant weight loss affects the breasts through loss of breast tissue and often creating a breast mound sag.

2) Breast implants can produce a dramatic change in breast size and shape in breasts that have lost a lot of volume. (weight loss breast augmentation)

3) Breast implants alone will work in the weight loss patient IF the position of the the nipple is at or just below the inframammary crease.

Dr. Barry Eppley

Indianapolis, Indiana

February 11th, 2017

Case Study – Chronic Abdominal Seroma after Tummy Tuck

 

Background:  A tummy tuck is a remarkably effective procedure that achieves its effect through wide excision of loose abdominal skin and fat and underlying muscle tightening. The raising of the upper abdominal skin flap to cover the removed lower abdominal tissue creates a large surface area of wounded tissue. This results in an expected serous fluid leak from these injured wound edges after surgery. This has been the historic reason that drains are placed during tummy tuck surgery and maintained for variable periods of time in the early healing period.

While there has been a recent trend towards the concept of the drainless tummy tuck, which strives to slow down or eliminate abdominal seromas through the use of quilting sutures, the risk of a subsequent fluid collection is not zero. Drained and drainless tummy tucks both have abdominal seroma risks.

The typical and usually very effective treatment for a seroma is needle aspirations and time. Once the internal tissues heal more the fluid leak usually ceases. In some cases a drain may be placed if the needle aspiration volumes are persistently high. But in very rare cases fluid colletion persist for a very long time or seemingly redevelop in an abdominal area with a prior history of a fluid collection.

Chronic Abdominal SeromaCase Study: This 50 year-old female had a history of having a tummy tuck nearly two years previously with the prolonged use of a drain. (8 weeks after surgery) Thereafter, she had a persistent area of firmness between the belly button and the lower abdominal scar line but it remained flat for a long time. Then six months ago (1 1/2 years after the surgery) the area mysteriously began to enlarge. She underwent radiofrequency treatments by her initial surgeon but it did not help and the area kept getting bigger.

Mini Tummy Tuck Sero0ma Surgery design Dr Barry Eppley IndianapolisChronic Abdominal Seroma Surgery Dr Barry Eppley IndianapolisUnder general anesthesia, a skin excision pattern was marked out for removal of excess skin that have been created from the expanding abdominal mass. The original tummy tuck scar was opened and dissection was carried down until a dark mass was encountered. This was an obvious encapsulated mass which expressed a large amount of dark fluid when it was entered. The cavity opened revealing a very thick encapsulated  lining on the abdominal fascia and into the overlying subcutaneous fat. The entire capsule  was removed, quilting sutures used and a small drain placed. The excess skin was removed, in the form of a mini-tummy tuck, and the outer abdomen thus re-tightened.

A delayed chronic seroma after a tummy tuck is very rare. This is only the second one that I have ever seen. They both have been associated with an early persistent fluid collection that either required prolonged use of a drain or the need for frequent needle aspirations. A firm abdominal mass that persisted thereafter for a long time as a bulge would represent an original undrained seroma. But this case represents an area that was flat (albeit firm) and then started to grow long after surgery. The exact mechanism for this phenomeon is not clear but its treatment would be the same for a chronic seroma that persisted much earlier after surgery.

Highlights:

1) The most common ‘complication’ after tummy tuck surgery is  seroma or fluid collection.

2) Most abdominal seromas are solved through healing time, needle aspirations and, ocasionally, the use of drain.

3) A chronic seroma is a very rare late tummy tuck complication that appears months to years later as a firm abdominal bulge that must be treated by open excision.

Dr. Barry Eppley

Indianapolis, Indiana

February 10th, 2017

Chin Implant Mental Nerve Compression

 

Contemporary chin implants, often called anatomic chin implants, have extended wings of material that go back along the jawline. This change in the shape of chin implant was done decades ago to overcome the aesthetic shortcomings of the old style button chin implants which often looked like a round circle sitting on the front end of the chin.

While these extended wings on the chin implant have their aesthetic value, they also create other potential problems. Should the chin implant end up having a tilt to its alignment along the lower edge of the bone, the chin will develop asymmetry. While such chin asymmetry is an aesthetic complication, the more significant complication can come from mental nerve compression.

If the wing of the chin implant from an asymmetrical placement or shift of the implant gets close to the exit of the mental nerve, nerve impingement symptoms may develop. These can include numbness of the nerve’s distribution (lip and chin) but, more importantly, pain. The pain can be constant or can mainly occur only pressing on the nerve area. While some temporary numbness can occur from any chin implant procedure, it is the symptom of pain that alerts to the possibility of mental nerve compression.

Chin Implant Mental Nerve ImpingementWhile the symptoms alone may be sufficient to make the diagnosis, a 3D CT scan will show clearly the implant’s exact location relative to the mental nerve foramen. In today’s facial implant surgery, there is no reason to guess or presume one knows where the implant actually is. A 3D CT scan ends all that debate.

If a chin implant wing is compressing against the mental nerve, the sooner it is relieved by implant repositioning the better. Prolonged compression can cause axonal death and result in permanent nerve injury.

Dr. Barry Eppley

Indianapolis, Indiana

February 9th, 2017

Clinic Snapshots – Rib Removal Waistline Narrowing

 

Rib removal is an aesthetic body contouring procedure that has an impact on narrowing the anatomic waistline. It is most commonly performed in my experience on already lean women that are trying to achieve an ultra narrow waistline or on male to female transgender patients to get some semblence of a waistline shape. While historically portrayed as an urban myth, rib removal surgery is very real and effective in the properly selected patient.

Rib Removal results front view Dr Barry Eppley IndianapolisTo create a waistline narrowing effect, the free floating (11th and 12th) ribs are shortened in their length. The concept of rib removal does not mean the entire ribs are removed back to their vertebral facets. Rather they are shortened back to the lateral border of the erector spinae muscle. This removes some support from the overlying soft tissues but does so without risk to any internal organs. This collapse inward of the soft tissues creates the waistline narrowing effect.

The debate in each patient is whether a portion of rib #10 should also be removed in addition to ribs #11 and #12. Rib #10 is not a free floater and has a more horizontal orientation. Its removal has less of an effect on the waistline than the lower two but a portion is often removed as well.

Rib Removal result back view. Dr Barry Eppley IndianapolisTraditional rib removal by chest surgeons is done through long incisions. But that is not acceptable in the cosmetic patient. Aesthetic rib removal is done through a 4 to 4.5 cm long incision placed in an oblique skin fold seen when the patient turns at the waist. This produces a far more acceptable incisional tradeoff. This patient picture shows the result seen just two days after rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

February 8th, 2017

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

 

Cheekbone reduction surgery typically is done by a double osteotomy technique. The anterior cut allows the posterior body of the zygoma (main body of the cheekbone) to move in. The posterior cut is done at the back end of the attached zygomatic arch just in front of the ear. These two cuts allow the whole side of the cheekbone to move inward. This creates the facial narrowing effect.

The anterior cheekbone osteotomy is done from inside the mouth and various design patterns have been described for it. But regardless of the design of the bone cut, it needs to be secured with a plate and screws to prevent inferior migration and sagging cheek soft tissues. Failure to do so is the most common cause of postoperative loss of cheek volume.

Posterior Zygomatic Arch Osteotomy Cut Dr Barry Eppley IndianapolisConversely, the posterior cut through the back end of the zygomatic arch is done externally through a skin incision. By making an incision at the back end of the sideburn hair, direct access can be done right down to the temporal process of the zygomatic arch.  An angled bone cut is then made just before the arch joins the temporal bone. This bone cut, combined with the anterior bone cut, allows the whole cheekbone segment to move inward. With plate and screw fuxation of the anterior, such rigid fixation may not be needed on the posterior cut to hold it in. The angled cut allows the tail of the arch to move inward and being self-locking.

Dr. Barry Eppley

Indianapolis, Indiana

February 8th, 2017

Case Study – Custom Chin Implant

 

Background: Chin augmentation has been around for a very long time and many implant materials and sizes have been used to do it. From this experience has come standard implant sizes that work for the vast majority of people seeking chin enhancement surgery.

But some patients seek changes that exceed what these standard size can create or have discovered through prior surgery that their expectations have not been met. In these cases only a custom designed implant may suffice.

Custom Square Chin Implant Design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a prior history of multiple chin procedures including a square chin implant and a sliding genioplasty. While all of these procedure produced a better chin, they fell short of his ideal chin shape and size goal. Therefore a custom chin implant was designed that brought the chin forward 25mm and gave it a very square shape without having any lateral wings.

Custom Square Chin Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia and through a existing submental incision the custom chin implant was placed over the end of the chin bone after removal of the indwelling implant. It was secured with a single 2.0mm titanium screw.

Custom Square Chin Implant front view Dr Barry Eppley IndianapolisCustom Square Chin Implant result oblique view Dr Barry Eppley IndianapolisAt six months after surgery his chin shape was more square with some increased projection. He was pleased and had finally reached his aesthetic chin shape goal.

While custom chin implants can be made to any size and shape, it is important to consider how the soft tissue chin pad will drape over it. (or whether it will) While not all custom chin implants are of large dimensions, many are. The chin soft tissues will not adapt well with large amounts of spontaneous horizontal projection. This often causes tight tissues, lower lip stiffness and an abnormal appearance. It helps to have the chin soft tissues stretched out from prior chin augmentation procedures which is often the case before many patients seek a custom chin implant solution.

Highlights:

1) A custom chin implant is needed when the dimensions of standard chin implants can not create the desired effect.

2) An implant that provides significant horizontal projection with limited width requires a  custom design.

3) Very large chin implants require previous soft tissue expansion from prior chin augmentation procedures.

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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