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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.

June 18th, 2017

A Clinical Outcome Study of Nasal Implants (Alloplastic Rhinoplasty)

 

There is an inevitable need in rhinoplasty surgery in some patients for augmentation. Whether it is for smaller defect corrections or for an overall major dorsocolumellar increase, volume addition to the nose is not infrequently needed. There is no question that cartilage grafting is the best tolerated form of nasal augmentation with the lowest risk of infection. But they are not perfect and cartilage grafts have their own issues from donor site harvesting, structural and shape constraints and an increased technical skill for their use.

As a result, the use of a variety of implant materials in the nose will always persist. Despite their often negative perception implants do have a role to play in the nose and any clinical series ion substantial volume and follow-up is always worthy of review.

In the April 2017 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases’. In this paper the authors  report on their experience in over 300 cases of nasal implants. It is important to distinguish what they mean by soft and firm nasal implants. The ‘soft’ nasal implants they used were synthetic polyester sheets (mersilene mesh) which is used for other surgical applications as its origins. These are sheets of monofilament fibers whose structure permits soft tissue ingrowth. These mesh implants were used in the tip, dorsal and side walls of the nose in varying thicknesses. Such soft implants were used in the majority of their cases. (87%, 269/311) The average implant thicknesses were 1.5mm or less. The firm implants were solid silicone L-shaped nasal implants. The thickness of these implants were 5mms or less. In some cases the tip of the nasal implant was covered by fascia or morselized cartilage. Such firm implants were used in the remainder of their cases. (13%, 42/311)

The infection rate in the soft implants occurred in 6% of cases (15 patients) Revisions for aesthetic purposes was done in 3% of the patients. (7 in number) Conversely no infections occurred with firm silicone implants. Aesthetic revisions were done in 7% of the cases. (3 in number)

The use of implants in the nose, known as alloplastic rhinoplasty, has its share of detractors. For some rhinoplasty surgeons the use of synthetic materials in the nose is never done while other surgeons use them routinely as is the case in this paper. Implants do have their unique set of advantages including volume stability, lack of the need for a donor site, versatility in shaping of the implant and often shorter operative times.

In this paper the authors show a very acceptable and low rate of implant infections as well as the need for revisions. In my opinion this was not due to the implant material but in how it was used. The key to their success is that they did not ask the implants to ‘do too much’. The implants usually had low thicknesses even in the solid silicone implant group. While one can get away with a lot of soft tissue stretching or even mucosal perforations with cartilage grafts, implants are much less tolerant of these soft tissue issues. Probably the greatest contribution this paper makes to the rhinoplasty literature is that implants can work fairly well in the nose when judiciously and selectively used.

Dr. Barry Eppley

Indianapolis, Indiana

June 18th, 2017

The Role of Custom Chin Implants

 

Alloplastic chin augmentation is the oldest facial implantation procedure. As a result, many different styles and sizes of chin implants have been used over the five decades of the procedure being performed. While in the vast majority of patients standard preformed chin implants work just fine, they do not always achieve the patient’s aesthetic lower facial reshaping goals. It is important to remember that current chin implants styles are based on historic patient’s aesthetic needs and surgeon experiences as well as what is economically feasible for the manufacturer. (they can’t produce endless styles of chin implants that end up having few commercial sales)

It is also relevant that today’s patients may have different aesthetic goals than that of what was popular ten or twenty tears ago. Patients are also becoming increasingly sophisticated as to the nuances of their facial aesthetics and, in some ways, are becoming more ‘3D’ in the desire for their facial changes. There is also the patient who has had a standard chin implant and is dissatisfied with the result due to shape issues.

As a result, there is an increasing role for custom chin implants. Even though the chin implant is the ‘simplest’ of all facial augmentation procedures that does not mean it is always easy to get a pleasing chin augmentation outcome. Contrary to popular perception the revision rates of chin implant surgery is not as low as most patients and surgeons believe. I have seen many patients who are on their second or third chin implant seeking an improved result.

Customizing a chin implant design can achieve several shape improvements over standard chin implants. First and foremost it can provide a horizontal projection versus width ratio that is not available in standard styles. Secondly, it can create a vertical lengthening increase with horizontal and transverse widths that is not currently available. Third, the wings of the implant can be designed to blend in better along the inferolateral borders of the lower jaw. Lastly, features such as a vertical chin cleft can be added.

Dr. Barry Eppley

Indianapolis, Indiana

June 17th, 2017

Waistline Narrowing with Rib and Muscle Removal

 

Rib removals for waistline narrowing is the final step for maximal waistline narrowing. After weight loss, exercise and liposuction the final anatomic ‘obstruction’ remains that of the lower ribs for optimal. What differentiates the lower or free floating ribs from those above it is that they are bony appendages with terminal ends. They do not connected to any ribs above it and, as a result, have a different angulation. Rather than having a more horizontal orientation, they point much more downward. (this is in contrast to many anatomic depictions which show them to be more horizontal in orientation)

The lower two ribs (11 and 12) are known as the free floating ribs because they do not connect to any other ribs and only have a proximal attachment to the spine. The remaining ten pairs of ribs above connect, directly or indirectly, to the sternum. Without a connection this allows the ribs to angle more downward or ‘float’. The reality is that the floating ribs do have firm soft tissue connections at their cartilaginous tips to the abdominal musculature. Thus when the floating ribs are removed the waistline collapses inward due to loss of both structural bony support and their muscular attachments.

One key question in rib removal surgery is whether rib #10 above the free floating ribs would also provide some waistline narrowing effect. This has to be determined by physical examination before surgery. Patients with shorter vertical waistlines usually do while taller patients with longer waistlines may not. But when in doubt rib #10 can be taken and dissected around the waistline to be disarticulated from its cartilaginous attachment to rib #9 at the inferolateral subcostal region. Like ribs #11 and #12, it can still be removed through the same small oblique back incision of 5 cms in length.

One additional technique that I have added to rib removal surgery is to remove a piece of lastissimus dorsi muscle over the removed rib area. The thickness of the muscle allows for an increased waistline narrowing effect by about 1cm per side. Loss of part of the lower end of this back muscle has no functional consequences. To avoid any risk of seromas and to ensure good skin adaptation back down to the recontoured soft tissues, quilting sutures are used. Drains have never been used for rib removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

June 12th, 2017

OR Snapshots – Neurovascular Bundle Preservation in Rib Removal Surgery

 

Rib removal can be done for a variety of aesthetic and medical purposes. The most common aesthetic reason is for horizontal waistline narrowing with the subtotal resection of the truly free floating ribs. (#s 11 and 12) Through a small obliquely oriented skin incision on the back the midportion of the ribs are identified just lateral to the erector spine muscle and cut. From that position the rib is then dissected out to its cartilaginous tip and removed.

One of the keys to rib dissection is that it is done in a subperiosteal plane. The periosteum is tightly wrapped in a circumferential manner around the bony rib. Getting under this tissue layer allows for the smoothest and cleanest plane of dissection but also preserves all surrounding structures. This is most relevant to the neurovascular bundle that sits in a groove on the inferior side of the rib. Elevating and preserving the artery and vein makes not only for less intraoperative bleeding but prevents inadvertent nerve injury/transection and the potential for chronic postoperative rib pain.

The subperiosteal rib plane of dissection is easiest on its superior aspect and harder to get out the neuromuscular bundle from its inferior bony groove. But the same instruments that are used to dissect the mucoperichondrium from the nasal septum are used to get the neuromuscular bundle out of its bony groove. Once started more proximal it is much easier to elevate out to the cartilaginous end of the rib. Once the rib is removed the vessels and nerve should be seen intact in the periosteal soft tissue cuff.

Rib removal is often associated with a destructive and very invasive surgery, undoubtably influenced by thoracic surgery  which has a different intent for its performance. From an aesthetic stand point it is important that rib removal be doing through small incisions and minimize any risk for chronic postoperative pain from intercostal nerve injuries.

Dr. Barry Eppley

Indianapolis, Indiana

June 12th, 2017

Case Study – Costo-Iliac Impingement Syndrome Treatment by Rib Removal

 

Background: The Costo-Iliac Impingement Syndrome, also known a the Rib Tip Syndrome, is a well known syndrome of back and hip pain caused by the touching of the 12th rib against the iliac crest. It most commonly occurs in patients who have had osteoporosis of the spine and loss of vertebral height. This allows the spine to curve and bend towards one side. It can also occur in patients with congenital scoliosis as well as younger patients who have a naturally longer 12 rib or an accentuated angulation downward at its takeoff from the spine or from a previous fracture.

Diagnosis can be done by physical examination and history as most patients can tell you that they know the rib is touching their hips. Deep palpation can feel the length of the 12th rib on its course downward.  The pain can be provoked by lateral flexion on the affected side. Ribcage x-rays can confirm the diagnosis. Definitive treatment is subtotal resection of the 12th rib on the affected side. Few clinical series exist but the few that have been published report relief of symptoms 100% of the time.

The free floating ribs (#s 11 and 12) have a different angulation from the spine than that of the superior ten ribs. Because their anatomy is not to wrap around the waistline or chest, they have a more downward angulation rather than a horizontal one. While many anatomic representations show the 11th and 12 ribs, I am often impressed how significant this downward rib angulation is in the many posterior rib removal surgeries that I have done. It is often 60 to 75 degrees downward in many cases, greater than what textbook illustrations would led you to believe. It is easy to see how it is possible that it could touch the hips in flexion in some short-waisted patients.

Case Study: This 30 year-old female was bothered by left hip/back pain on flexion to that side in numerous body positions. She was well aware that it was probably rib-related. Palpation revealed a long 12th rib that was at the level of the iliac crest. On bending to that side the discomfort could be elicited. For purposes of symmetry and any waistline reduction benefits, bilateral rib removals were planned.

Markings done before surgery showed the relationship of the 12 rib to the height of the iliac crest. Bilateral subtotal 11 and 12th ribs were done through 4.5 cm long oblique back incisions.

Provided a proper diagnosis is done before surgery, one can expect a near complete resolution of hip and back pain from the Costo-Iliac Impingement Syndrome with subtotal rib removal. Whether one chooses to add rib 11 along with 12 depends on the preoperative physical findings and the patient’s goals. If any doubt about rib length or angulation a 3D ribcage CT scan should be preoperatively done. This will remove all doubt about the shape of the lower ribcage anatomy.

When removing any rib for aesthetic or functional purposes, preservation of neurovascular bundle at the inferior edge on the rib is important. Injury to the intercostal nerve during its dissection could potentially end up trading off one source of pain for another.

Highlights:

  1. The Costo-Iliac Impingement Syndrome is due to a long or severely angulated 12th rib that touches the top of the iliac crest in flexion or sitting.
  2. An effective treatment for this syndrome is subtotal removal of the 12th rib and even the 11th rib if necessary.
  1. For purposes of waistline symmetry, bilateral subtotal rib removals can be done.

Dr. Barry Eppley

Indianapolis, Indiana

June 12th, 2017

Circumferential Body Lift – Safety and Effectiveness Evaluation

 

The large amount of obesity isn America has created the need for bariatric surgery over the past two decades. With large amounts of weight loss has come the resultant excess skin issues which poses their own set of medical and personal hygiene and self-image issues. A number of bariatric plastic surgery procedures have been developed and modified over the years to manage the loose and sagging skin over the trunk and extremities.

What is fundamentally unique about many of the these bariatric plastic surgery procedures is the large body surface areas that they cover and the length and extent of surgery to treat them. This is on top of any underlying medical issues that a weight loss patients may have. Together this has created a known high rate of complications after this type of body contouring surgery. The circumferential body lift is the most extensive of these types of procedures and any series that reports their experience its noteworthy to define the effectiveness and risk of the circumferential body lift.

In the June 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Safety of Outpatient Circumferential Body Lift: Evidence from 42 Consecutive Cases’. In this paper the authors review their experience in this type of body contouring surgery over a six year period looking at complications and the occurrence of revisions. Of note on their technique and protocol; the posterior lift was performed first in the prone position, a urinary catheter was not used, the anterior portion was performed with liposuction of the epigastric area and a diastasis repair, and drains were used in both the back and front. No drug prophylaxis for DVT was given but sequential compression devices were used during surgery with compression stockings after surgery. The vast majority of the patients were female (41 out of 42) with an average weight loss off over 120lbs. A few patients (12%) had the fleur-de-lis modification to the front tummy tuck part of the body lift. Total average operative time was just over 2 1/2 hours.

The overall complication rate was 36% with the vast majority related to what would be expected in a large body surface area operation with a long incision…wound separation (24%) and seromas. (5%) The wound separations occurred usually over the sacrum which is both common and expected. The revision rates were 26% and were usually done for scar revisions. There were no adverse medical events including deaths, DVTs, hematomas or the need for hospitalization for any reason.

This paper supports that circumferential body lift surgery is both safe and effective and can be done in an outpatient facility. Overnight observation is useful particularly in patients that do not live close to the site of surgery. High satisfaction rates are typical for this type of operation, even with complications, given the dramatic changes that result and the lack of any other alternatives to solving the large amount of loose and sagging skin.

Dr. Barry Eppley

Indianapolis, Indiana

June 11th, 2017

OR Snapshots – Extended Temporal Implant

 

Temporal hollowing is commonly treated by injectable fillers and fat injections. While both of these injection methods have their merits, the assured permanent temporal augmentation method is with the use of an implant. Temporal implants are newer forms of facial implants that are specifically designed to replicate the soft feel of muscle rather than that of bone. It is the only facial implant that is designed to augment a soft tissue area.

Temporal hollowing is the result of fat atrophy, muscle wasting/thinning or a combination  of both. In modest to moderate amounts standard temporal implants do well in improving hollowing. They cover the lower half  of the temporal region from the zygomatic arch upward to the level of lateral brows.

In more severe forms of temporal hollowing the concavity extends up to the anterior temporal line at the side of the forehead. This encompasses the entire anterior temporal zone for which the standard implant is deficient in height. (vertical length) As a result an extended temporal implant has been designed that can augment the entire extent of temporal hollowing should it go all the way up to the forehead.

The extended temporal implant is placed through the same incision as the standard style. The length of the incision does not need to be extended to properly place it. Once the pocket is made the implant is inserted in a horizontal orientation and then turned 90 degrees for proper placement.

The extended temporal implant offers enhanced improvement for those so afflicted with more severe facial hollowing. Thin females, patients with medication-induced facial lipoatrophy, and extreme weight loss patients are the most common aesthetic indications for use of the extended temporal implant.

Dr. Barry Eppley

Indianapolis, Indiana

June 11th, 2017

Case Study – Two-Stage Skull Augmentation with Custom Implant

 

Background: The size of one ’s head is a personal matter based on how one sees it. Some people feel their head is too big while others feel it is too small. While there are specific ratios and numbers for head to face size, what ultimately matters is how the person themselves see it. I have seen a lot of patients with concerns about their head size and in most the cases their concerns are visibly evident.

A larger head is hard to hide but a smaller head size can be camouflaged through a variety of head wear and hairstyles. Women can camouflage a smaller head size using their hair. Fuller hairstyles give the illusion of a bigger head. But eventually some women tire of the effort of making their hair a certain way or their hair becomes damaged by continually doing so.

The small head can be augmented to some degree using custom skull implants. The thickness of the skull bone can be doubled in many cases to create an overall larger head size. How much a skull implant can do so depends on the natural stretch of the scalp, which can not be precisely determined beforehand.  My experience has shown that about 12mms of central implant thickness can be tolerated in most people. The scalp can safely stretch over an implant and allow for a comfortable incisional closure. More implant thickness or volume requires a first-stage scalp expansion procedure.

Case Study: This 30 year-old female ha done been bothered by the small size of head. She wanted a head that was taller and face her better balance to her face. A 3D CT scan showed a skull shape that  was normal but did not have a convex shape to the top. It has more of a flatter profile from front to back.

Her 3D CT scan was used to make a custom skull implant that added a lot of height (1t5mms) as well as broader coverage over the rest of her skull. Given its desired size it was felt that her scalp would not stretch enough to be placed without a first stage expansion.

A scalp tissue expander was placed in a first operation with a remote port placed under the skin above the right ear. She was able to place 110cc of saline volume into the expander over the next six weeks.

During a second operation the custom skull implant was placed  through a minor extended scalp incision that was limited to just across the top of her head. The scalp closure was tight but closed comfortable with metal clips.

Her results at just two weeks after surgery showed a nice increase in her head height and a well healing scalp incision.

Larger or more extreme skull augmentation require scalp expansion first. At the time of the implant placement the capsule from the expander misty bone removed from the bone as well as from the edges of the expander capsule. This will allow the scalp to fully maximize its expansion through these scar releases.

Highlights:

  1. The size of any skull implant depends on the stretch of the soft tissue to accommodate it.
  2. Larger skull augmentations require a first-stage skull expansion to ensure that there will be enough scalp to close over it.
  3. The timing between the placement of a scalp tissue expander and the secondary placement of a skull  implant is usually around six weeks.

Dr. Barry Eppley

Indianapolis, Indiana

June 11th, 2017

The Anterior Septal Angle in Rhinoplasty

 

The open approach is the most commonly used technique in contemporary rhinoplasty. Whether it is a primary nose or a secondary revision, the open approach provides wide access and visualization of all nasal structures. But once inside how does the plastic surgeon decide to proceed?.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘The Importance of the Anterior Septal Angle in the Open Dorsal Approach in Rhinoplasty’. In this review paper the authors discuss the importance of the anterior septal angle as it contributes to nasal tip support and length as well as internal nasal valve anatomy and airway function. There are many important nasal maneuvers that can be from the anterior septal angle from spreader grafts, septal angle reduction, septoplasty and cartilage harvest to caudal septal resection and the placement of columellar strut grafts.

The importance of the anterior septal angle is described using the four gateways. The dorsal gateway allows for dorsal aesthetic line creation/restoration, septal reduction and spreader grafts and correction of the deviated noise with spreader grafts. The posterior gateway allows for airway obstruction improvement by septal correction back to the vomer as well as cartilage harvest with emphasis on maintaining 10 to 15mms of L-shaped septal construct. The nasal tip gateway looks at the role that the anterior septal angle plays in tip support, specifically the use of septal extension grafts to control tip projection and shape. Anterior septal angle reduction can also be done in the tension nose to help widen the external and internal valves. The caudal gateway allows for the placement of columellar strut grafts and depressor septa muscle transection.

What has become apparent after decades of performing open rhinoplasty surgery is that the identification of the anterior septal angle is the first step after exposure or degloving of the nose is done. From this anatomic point all structural changes can be initiated.

Dr. Barry Eppley

Indianapolis, Indiana

June 10th, 2017

Tear Trough Fat Grafting During Lower Blepharoplasty

 

Lower eyelid aging creates a number of well known aesthetic deformities. From excessive skin, herniated orbital fat, malar-palpebral grooves to tear troughs, the anatomic changes to the lower eyelid have been well chronicled. Tear troughs and the correction of this nasojugal groove have been treated by both injected fillers and fat as well as different surgical blepharoplasty techniques.

The surgical correction of the tear trough deformity has included orbital fat transposition, release of the orbitomalar ligament and tear trough implants….or some combination of them. While these can be done using an external skin or an internal conjunctival approach, the most consistently effective is the external approach or the skin-muscle flap technique. Its enhanced visibility allows for the redistribution/rearrangement of local tissues to a reproducible autologous rejuvenation effect.

In the June 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty’. In this paper the authors report their results of 32 lower blepharoplasty patients who had their tear trough deformities treated by the addition of micro free fat grafts with an average followup of one year. In their technique they minced any removed orbital fat pockets into small 2mm to 3mm grafts. (micro free fat grafts) These are then placed into a space created by the release of the orbitomalar ligament. Their results showed consistent good improvement of the tear trough deformity. No patients developed infection or lid deformities. One reoperation due to sclera show was needed (3%) while temporary conjunctival swelling occurred in just over 10%.

Traditional lower blepharoplasty techniques in the face of tear trough can often leave them looking worse by exacerbating the appearance of the preoperative hollows or dark circles. The concept of not merely discarding herniated orbital and reusing it either through pedicled flap transposition or free fat grafts is a logical one. What is appealing about free fat grafts is that they are more versatile than a peddled flap. They can be placed more consistently, in greater volumes and with more precise placement. Such solid small fat grafts have been known to survive for as long as thirty years ago with reports of the use of ‘pearl fat grafts’ in the face.

Free fat grafting of the tear trough during lower blepharoplasty can be done with fat harvested from anywhere not just the use of orbital fat. Small grafts taken from the buccal fat pad is a good example of a regional fat donor source. Whether its survival is as good as orbital fat can not be determined but there is no reason go think that it would be less.

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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