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.

August 6th, 2017

Long-Term Outcome of ePTFE Ear Reconstruction

 

Ear reconstruction for partially or completely removed/lost ears in adults must take into consideration the needed soft tissue coverage. While the cartilage of the ear can be replaced by either a synthetic framework or rib cartilage, it requires vascularized tissue and a skin graft to have a reconstruction result that survives and hopefully looks good. Contrary to the understandable perception of some patients, you can’t just put a skin graft directly on cartilage or a synthetic material.

In most cases of major ear reconstruction, the key element is what is known as a TPF flap. This stands for a temporoparietal fascial flap. Fed its blood supply by the ascending superficial temporal artery passing in front of the ear, this is the fascial layers (excluding the deep fascia) overlying the temporal muscle on the side of the head. This thin tissue can be raised off the entire temporal muscle and turned down to cover a synthetic or cartilage ear framework. It is onto this tissue that a skin graft can then be placed to complete the third layer of the reconstruction.

What is important for patients to understand is that healing of these complex ear reconstruction is a process. Right after surgery and for the first month or so the ear reconstruction often looks little like an ear. The tissues are swollen and distorted and it can just look like a swollen indistinct mass one the side of the head. It takes time for the swelling to goo down and, just as importantly, the overlying soft tissue coverage to shrink down and stick into all the details of the framework. Here is an example of a partial ear amputation due to skin cancer with an immediate ePTFE framework covered by a TPF flap and skin graft. It sort of looks like an ear at the end of surgery but will get quote swollen and distorted for weeks afterward.

When seen at three months after surgery, the ear looks more defined and some of the details of the framework can finally be seen. While it will never look exactly like what was removed, it creates an acceptable looking result.

The long-term aesthetic outcome of ear reconstruction awaits the contraction of the thin overlying vascularized tissues to adapt to the framework. This ‘shrink wrap’ effect is a process that takes months after the surgery to reveal its full effects.

Dr. Barry Eppley

Indianapolis, Indiana

August 6th, 2017

Case Study – The Posterior Sagittal Crest Reduction

 

Background: The sagittal suture is the fibrous connection between the two parietal skull bones running down the midline of the head. It remains as a soft tissue connection until the second or third decide of life when it closes and disappears. Premature closure of the suture in utero or early after birth results in the well known scaphocephaly condition or sagittal craniosynostosis. Skull growth is inhibited perpendicular to the suture and, as a result, the head becomes very elongated and narrow in width shortly after birth.

The sagittal suture connects anteriorly with the coronal sutures whose interface is known as the anterior fontanelle early after birth and later as the bregma when the soft spot closes. The sagittal suture connects posteriorly with the lambdoid sutures which is known as the posterior fontanelle in the first few years of life and later as the lambda when the fontanelle closes.

In some individuals a raised sagittal crest develops along the original line of the sagittal suture. It is usually highest just in front of the lambda and decreases in height coming forward towards the bregma. This is known as the posterior sagittal crest deformity. A line may be seen coming all the forward to the forehead but the highest point is in the back, making the skull height highest at the back end of the sagittal suture rather at the vertex in the middle portion of the suture lines.

The posterior sagittal crest deformity is an aesthetic skull deformity that is seen exclusively in men in my experience. This is probably because it becomes an issue for treatment when hair loss occurs and men shave their heads. It appears as a distinct triangular point in the front view and gives the head a midline peaked appearance.

Case Study: This young male presented for treatment of his raised posterior sagittal crest. It appeared as a raised ridge in the side view and as a triangular point in the front view. A 3.5 cm curved scalp incision was marked just behind the posterior crest for surgical access.

Under general anesthesia, the scalp incision permitted a midline subperiosteal tunnel to be made into which a handpiece and burr was placed for reduction. The crest of bone mass reduced by burring from back to front to reduce its height and make for a smooth contour into the sides. Cleaning out the bone dust allowed it to shaped into a pasty mound representing the amount of crestal bone removed. The incision was closed in layers with fine dissolvable sutures for the skin.

The posterior sagittal crest represents one part of the sagittal suture that closed just a bit early but not enough to create the full blown expression of sagittal craniosynostosis. It always affects the back part of the sagittal suture with lesser degrees of bone height coming forward. It is effectively reduced by a bone burring reduction. It is important to wash out all bone dust created and to seal any bleeding vessels in the bone with wax to ensure reactive bone formation done not occur.

Highlights:

  1. The posterior sagittal crest represents a microform of sagittal craniosynotosis that partially affects just one part of the suture.
  2. Burring reduction of the raised part of the suture line is done through a small scalp incision.
  3. The raised sagittal crest represents thicker bone so complete reduction of it is usually possible.

Dr. Barry Eppley

Indianapolis, Indiana

August 6th, 2017

OR Snapshots – The Fate of the Cut Muscle Edge in Temporal Reduction

 

Temporal reduction is an effective method for narrowing the wide head. The wide head is defined as the area above the ears that has too much convexity or fullness. Extreme fullness at the sides of the head occurs when the width of the head gets near a vertical line drawn up superiorly from the inside of the superior helix of the ear. But many affected patients may feel they have too much convexity even when its width is well inside the profile of the ear.

While many feel that temporal bone reduction is the key to head width reduction, it actually is not. The thickness of the posterior temporal muscle is what constitutes a significant part of the side of the head. Its removal makes an immediate and visible reduction in its convexity, changing it to a completely or near complete flat profile. Surprisingly the removal of the posterior temporal muscle has no functional impairment on lower jaw motion or function.

In the technique of temporal reduction by myectomy, which is usually performed through a postauricular incision, a vertical cut through the temporal muscle is made from the attachment of the ear superiorly to the temporal line at the top of the skull. All muscle behind this line is removed leaving the overlying fascia in place. With muscle thicknesses averaging 7 to 9mms in thickness this leaves a very palpable and sometimes visible step-off in the temporal contour. The posterior cut edge of the large remaining anterior temporal muscle is cauterized for both hemostasis and in the belief that muscle atrophy will eventually smoothest the shape of the cut edge of the muscle.

I had the opportunity to validate what happens to the back edge of the cut temporalis muscle. Three years previously as part of awn overall skull reshaping procedure, the posterior temporal muscle was resected in a full-thickness vertical fashion from the bony temporal line inferiorly down to the ear. In a more recent skull reshaping procedure on the same patient, the temporal regions were inspected. It was observed that the original cut edge of the muscle does thin out and recontour with healing as suspected.

 

Dr. Barry Eppley

Indianapolis, Indiana

August 6th, 2017

Technical Strategies – Transcoronal Posterior Zygomatic Arch Osteotomy

 

Cheekbone reduction by osteotomies is the only surgical method for narrowing a wide face. While most commonly performed on Asian patients all around the world, I have done an equal number on other ethnicities as well. By performing a bone cut through the main body of the cheek (zygoma) and at the back end of the zygomatic arch, the widest part of the cheeks can be moved inward. Its effect comes from taking the most convex part of the zygomatic arch and changing its widest point to a lower inward position. Once the bone is moved inward it is usually stabilized in its new position by some form of metal fixation.

The front cheekbone reduction osteotomy is done from an intraoral incision and thus is scar free. Conversely the posterior zygomatic arch osteotomy is usually done from an external skin incision at the back side of the sideburn (male) or preauricular tuft of hair. (female) While this small incision always heals well in my experience, there are alternatives points of access to it.

One approach to the posterior zygomatic arch osteotomy is through the same intraoral incision as the anterior osteotomy. Sliding an osteotome along the underside of the arch it can be fractured in a blinded fashion. Plate stabilization is not possible. This is not a technique that I have done but I know other surgeons that do it.

Another approach to the osteotomy its from above, coming underneath the deep temporalis fascia. This could be done if one is concurrently using a coronal scalp incision for other procedures as well. Thin elevators are placed on both the outside and inside of the posterior zygomatic arch just in front of its temporal attachment. An osteotomy is used to make a complete osteotomy through the thin arch bone. It can then be mobilized and pushed inward. Like the intraoral approach plate fixation is not possible.

Dr. Barry Eppley

Indianapolis, Indiana

August 5th, 2017

Technical Strategies – Submental Tracheal Reduction

 

The reduction of a prominent Adam’s Apple is known as a tracheal shave. Done directly over the tracheal prominence through a small skin incision the V-shaped thyroid cartilage is reduced, as the name indicates, by shaving it down with a scalpel blade. Since the prominence is composed of cartilage it can be reduced in layers with the sharp edge of a blade. As patients age the thyroid cartilage becomes stiffer and more calcified and may have to be burred down for an effective reduction.

While the skin incision for a tracheal shave is small and often heals exceedingly well, the risk of a visible scar always exists. While the procedure will always require a skin incision, an alternative location would be higher in the submental region under the chin. This distant incision location requires the creation of a subcutaneous tunnel down the midline from the chin to the thyroid prominence. Using a fiberoptic retractor the prominent cartilage can be seen and dissected free of overlying tissues.

Because the thyroid cartilage is a mobile structure, trying to shave it down with a scalpel blade from a remote incision is difficult. For this reason I prefer to use a handpiece and drill and burr the cartilage prominence down. This works just as well on soft cartilage as it does on harder cartilage. A small round or tapered carbide burr removes cartilage structure rapidly. Within the tight space of this subcutaneous tunnel it is important to be careful with a rapidly rotating burr to not inadvertently engage the surrounding soft tissues.

Because of the more limited visibility from this remote incision, a submental reduction should not be used when larger tracheal shaves are needed. Better control of the shape of thyroid prominence can be obtained by a direct incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

August 5th, 2017

Posterior Maxillary Reshaping for Lower Cheek Fullness after Large LeFort I Advancements

 

The LeFort I osteotomy is the most common midface bony procedure and has been a staple in orthognathic surgery for over a half decade. With a horizontal osteotomy line above the level of the teeth and across the base of the nose, the upper jaw is mobilized and moved in a variety of dimensional changes with a horizontal movement being the most common. Its amount of forward movement depends on the position of the lower teeth and jaw whether it is being moved or not. The typical Lefort I forward movements are usually in the range of 3 to 7mms in non-syndromic patients.

The need for large maxillary advancements in non-syndromic patients is most commonly done in the treatment of sleep apnea. Moving the upper and lower jaws forward together opens up the oropharyngeal airway as it brings both the base of the tongue and the soft palate forward. Such maxillomandibular movements are often in the range 8 to 10mms.

While typically very effective in improving or curing the patient’s sleep apnea, the appearance of the face often changes with these larger skeletal movements. While bringing the lower jaw and its chin position forward can be perceived as aesthetically advantageous in some patients, the midface changes may not be. As the upper midface is left ‘behind’ (infraorbital rims and cheeks) and the lower midface (maxilla) comes forward, its appearance can become different and may not be an aesthetic improvement.

One midface finding in some sleep apnea surgery patients is that their lower cheek develops a fullness. This is below the cheek bone and corresponds to directly over the maxilla at the level of the base of the nose. This fullness can feel firm rather than soft like fat. This fullness is the result of the back end of maxillary osteotomy now creating a projection or fullness (a step) rather than its natural concavity in this area. This its unique to large maxillary advancements that brings out the back end of the maxilla from underneath the cheekbone.

Correction of this problematic full midface fullness can be done by an intraoral posterior maxillary osteotomy and infracture. Through an intraoral approach and a small vestibular incision over the palpable bony bump, the base of the posterior maxillary protrusion is fractured back into the maxillary sinus. This changes the unnatural bony protrusion back into a more natural concavity and eliminates the external lower cheek fullness.

Dr. Barry Eppley

Indianapolis, Indiana

August 4th, 2017

Technical Strategies – The Vertical Opening Wedge Genioplasty

 

Chin asymmetry is easily seen as the most projecting part of the lower face is shifted off of the facial midline. The central chin point is shifted to one side or the other and can occur for variety of reasons. The most common reason is developmental or traumatic where the sides of the jaw have different lengths, most commonly because there is a shorter side due to developmental deformities or from traumatic injuries/fractures.

In cases of chin asymmetry due to shortening of one side, realignment of the chin can be done by a unilateral lengthening of the shorter side. This is called an opening wedge genioplasty which is performed through an intraoral approach. Just like a traditional sliding genioplasty a horizontal bone cut is done well below the mental foramens and at a low anteroposterior angle as possible. Once the bone is down fractured (mobilized) the the longer or normal side is fixed with a single small two-hole plate and screws with bone to bone contact. This becomes the hinge point at which the opposite shorter side is opened.

The opening wedge distance on the shorter chin side that it is vertically lengthened is determined by the distance the central chin point is off the facial midline. In theory this is a 1:1 ratio, although like an obtuse or scalene triangle, the opening wedge usually has to be slightly greater than the amount of midline asymmetry.

The opening wedge is then stabilized with a much longer plate than was used on the opposite hinge point. Cadaveric corticocancellous bone pieces are used to fill in the empty intrabony wedge space to ensure healing. It is important to fill out the wedge defect all the way out to the inferior border to avoid a step-off deformity.

The vertical opening wedge bony genioplasty is a useful technique for those chin asymmetries which are caused by a shorter sided jaw segment.

Dr. Barry Eppley

Indianapolis, Indiana

August 3rd, 2017

Case Study – Large Buffalo Hump Reduction

 

Background: The buffalo hump is a descriptive term that universally applies to a discrete collection of fat on the back of the neck. Looking at the American bison it is easy to see why it has its name with the massive shoulders of the animal being amongst its most distinct features. But unlike the bison, the human buffalo hump is not muscle but fat.

The dorsocervical collection of fat in humans both unusual and distinct for two reasons. First, it is not a typical location for fat to deposit as it is not known for being a metabolic depot site. It may reflect the congenital location of brown fat which is known to be present in newborns but diminishes with age. Secondly what activates the enlargement of the dorsocervical fat pad is not precisely known. Certain medications and illnesses are associated with its development but it can also occur in people who do have these drug or disease associations.

Case Study: This 22 year-old male presented for treatment for his large buffalo hump deformity. He was a large adult man (almost 300lbs) but he did not have any of the associated triggers for its development. It caused him neck pain and restricted his neck extension. He was also socially embarrassed by it.

Under general anesthesia and in the prone position,  a three-hole liposuction approach was used. Using power-assisted liposuction with baskets as well as smooth round-tipped cannulas the very dense fibrofatty tissue was aggressively treated with an aspirate volume of just under one liter. (900ccs)

His immediate result during surgery showed the degree of improvement which largely made the back of his neck flat again. Unfortunately there are no good methods of after surgery compression for the back of his neck so he will have considerable swelling which will take more than a month to return to this intreoperative result.

The traditional method of buffalo hump reduction was open excision. Due to its very dense fibrofatty tissue it was felt that liposuction could not get an adequate reduction. And if one was using traditional ‘elbow-driven’ liposuction this would still hold true. But today’s many power-driven liposuction technologies make it possible to reduce denser and more fibrous fatty areas like the buffalo hump. While not every case has such dense fibrous fat many buffalo humps do.

Highlights:

  1. The buffalo hump deformity is an abnormal development of fat in the dorsocervical fad pad.
  2. It is a often a dense fibrofatty tissue that requires a mechanized or energy-driven liposuction method for removal.
  3. An open excision of the buffalo hump can usually be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

August 2nd, 2017

Case Study – Linear Custom Jawline Implant

 

Background: Augmentation of the total lower third of the face is historically and most commonly done using standard implants. The combination of chin and jaw angle implants, a three implant approach, provides enhancement of the three corners of the lower face. While theoretically appealing and a good solution for many jawline needs, it can be unsuccessful for a variety of reasons. These include implant asymmetry, the inability of standard implants to provide the desired aesthetic result and the lack of connection between all three implants.

A custom jawline implant connects the chin and jaw angle regions in either a linear or non-linear fashion.The size or thickness of the connection between the chin and jaw angles of the implant determines whether there is a smooth or linear look going from the chin back to the jaw angles or whether the chin and jaw angles stand out more than what connects between them. (non-linear look)

Designing a custom jawline implant with existing indwelling implants is ‘easier’ and more helpful than if no implants were there at all. Knowing what the aesthetic effects of existing implants creates, even if undesired, helps guide a new implant design that may produce a better result. While the custom implant design process is greater from the standpoint of fit to the bone, symmetry of both sides of the implant and creating a unified look, the computer or surgeon has no way of knowing exactly what implant dimensions can exactly achieve the patient’s goals.

Case Study: This 45 year-old male had Medpor chin and jaw angle implants previously placed which did not produce the jawline look that he had hoped. Fundamentally it did not give the jawline angularity that he seemed and did not have a smooth connection between the chin and the jaw angles. In the implant design process his existing implants were digitally removed and a one-piece jawline implant designed.

Under general anesthesia and through a combined intraoral and submental existing incisions, his Medpor chin and jaw angle implants and their numerous large screws were removed.

His new custom jawline implant was placed using a split implant technique. Due to the size of the implant jaw angles and concerns about injury to the mental nerve when passing the implant from front to back as a single piece, the implant is first sectioned in the midline of the chin in a geometric interlocking pattern. This then permits the implant to be placed in two sections from back to front and then reconnected in the middle. This is safer for the mental nerve as the sizes of the implant that must pass underneath it is smaller.

His one day results show an immediate improvement in his jawline shape in a more connected fashion. (linear jawline look) There is also more angularity evident in the chin and jaw angle corners. While he will go on to have some tremendous swelling that will take up to month or more to fully resolve, his very early jawline result looks more favorable to his aesthetic goals.

Highlights:
1) Jawline augmentation by three separate preformed implants often does produce a satisfactory or desired shape of the lower third of the face.
2) With existing chin and jaw angle implants in place, a custom jawline implant can be designed for an improved facial outcome.
3) Contrary to popular perception, Medpor implants can be successfully removed although it is more traumatic to the tissues than that of silicone implant removal.

Dr. Barry Eppley
Indianapolis, Indiana

July 31st, 2017

Case Study – Vertical Breast Lifts with Implants

 

Background: The sagging of the female breast is a common sequelae to age, pregnancies and weight loss. The shape of a woman’s breast is rarely a static structure over their lifetime being subject to a variety of forces that work to make the breast mound lose its shape. Stretching of the mound skin and loss of breast volume are the anatomic reasons for ‘the breasts heading south’.

Correction of breast sagging, therefore, necessitates addressing the loose skin and lack of adequate volume. Various types of breast lifts combined with a large range of breast implant sizes creates options for rejuvenating the sagging breast mound.

The use of a combination breast lift and implant placement is a common breast reshaping procedure. But mixing the type of breast lift and the size of implant defies an exact scientific method to do so and not every women can get any breast implant size with their lift that they desire.

Case Study: This 34 year-old female had developed significant sagging and loss of breast volume after four pregnancies. She needed as much of a breast lift as she did that of more breast volume.

Under general anesthesia, she underwent a combined vertical breast lift with the placement of 400cc silicone breast implants. Her results shows that the size of the breast lift chosen can dictate how much of a breast lift result can be obtained.

In the combined breast lift and implant surgery, also known as an implant mastopexy, the effects of the two procedures often are at a conflict. Since a breast lift achieves its effect to some degree by skin removal and tightening and an implant exerts its effect by skin expansion, it is easy to see how combining these procedures often creates the need for compromise. For more of an uplifted and perky breast, a smaller implant must often be chosen. For larger implant volumes the amount of lifting effect will often not be as great.

Highlights:
1) Breasts lifts are often done at the same time as the placement of breast implants in certain amounts of breast sagging.
2) Large amounts of breast sagging or the desire for large breast implants may necessitate a staged approach to lifting and implant placement.
3) The use of breast implants in the sagging breasts may often be to just maintain upper pole fullness.

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.

Read More


Free Plastic Surgery Consultation

*required fields


Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories