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Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

September 3rd, 2017

Facial Skeletal Changes with Aging

 

The anatomic structure of the face is well known to change with aging from the outer skin down to the bone. This recognition of how the face ages provides for more effective treatment strategies. While once skin pulling and tightening was the only treatment approach, the understanding of the loss of fat with aging has led to the addition of fat grafting as part of anti-aging facial surgery.

In the August 2017 issue of the JAMA Facial Plastic Surgery Journal an article was published entitled ‘Patterns of Change in Facial Skeletal Aging’. In this paper the authors studied CT scans of over a dozen adult faces (ages 40 to 55) who had such studies done at least eight years apart that included the skull down through the midface. Measurements were made using landmarks on 2D scans as well as 3D reconstructions. Specifically, glabellar and maxillary angles as well as pyriform height and width were studied.Their results showed significant decreases in glabellar angles (- 2 degrees on average) and maxillary angles. (around 2 degrees on average) There were increases in pyriform width and height as well.

While the bony changes with aging has been studied before, this study is relevant because it assessed the same patients over different time periods. Opening up of the glabellar and maxillary angles as well and increases in pyriform height and width are signs of bone loss/atrophy. Such midface changes can be more severely affected with the loss of teeth although this was not specifically evaluated in this study. (I assume their patients had a reasonably intact maxillary dentition)

The real relevance of this study is whether some patients may benefit by bony augmentation as part of their anti-aging facial surgery. Specifically midface augmentation of the premaxillary-paranasal region may be considered. This could be especially helpful for the patient with deep nasolabial folds and a recessed nasal base.

Dr. Barry Eppley

Indianapolis, Indiana

September 3rd, 2017

Case Study – Massive Palatal Tori Removals

 

Background: The finding of a bony growth on the palate is most commonly the result of the development of a tori. They typically present as a small midline bony lesion less than a few centimeters in size in early adult life. They are capable of growth over one’s lifetime but it its usually very slow.

Palatal tori are very common and are estimated to occur in 10% to 20% of the general population. They are more prevalent in some ethnic populations but are also more often seen in females. It is not known why they occur but they can be inherited and have been claimed to be an autosomal dominant trait.

Palatal tori occur in different patterns and are classified based on their shape. They can occur as flat, spindle, nodular and lobular types. Nodular and lobular tori are usually bigger in size. Palatal tori are benign bony outcroppings that do not usually need removal unless they are a source of irritation or are an obstruction to the fit of dentures.

Case Study: This middle-aged female had large palatal for her entire life. She had a family history of her mother having large palatal tori as well. They occasionally became sore but she never considered removing them until she needed partial dentures. Her palatal tori consisted of four bony growths, two large smooth ones on the inside of the alveolar ridge at the molar area as well as a midline lobular one that had two large halves. All four tori merged together leaving just a narrow linear gap between them. (a source of food entrapment)

Under general anesthesia, laterally based mucoperiosteal flaps were used to expose the lateral tori for their reduction by a high speed burr and osteotomes. A t-shaped mucoperiosteal flap was used to exposed the bilobed midline tori for their reduction by a similar bore removal technique..

Massive palatal tori removal requires most of the hard palatal tissues to be elevated for exposure and adequate bone removal.  While effective, complete mucosal healing requires a few weeks and is fairly sore.

Highlights:

  1. Palatal tori are commonly a single midline bony lesion but four in a single patient is very rare.
  2. Removal of palatal tori may be necessary for the fabrication of partial or full dentures.
  3. The removal of palatal tori requires the reflection of full-thickness mucoperiosteal flaps.
September 2nd, 2017

OR Snapshots – Batten Rib Graft Rhinoplasty

 

The use of cartilage grafts in rhinoplasty are done for a wide variety of reasons. While all cartilage grafts add support, some of these effects are to improve the shape of the nose while others are to improve its breathing function. Of all cartilage graft placements, the nasal tip is the most common area in which they are used.

Cartilage grafts in the lower third of the nose are most frequently placed in the central tip area. Whether it is a columellar strut graft or a wide variety of tip augmentation/shaping grafts, increasing tip projection and/or support is critical to resist the potentially displacing effects of the overlying skin.

But the side walls of the nasal tip, or lateral alar regions, can occasionally need cartilage grafts as well. The lateral alar cartilages are responsible for keeping the nostrils more open for breathing and play a critical role in the shape of the nostrils as well. Extending from the tip down to the nasal base they encompass almost the full length of the nostrils like a spanning bridge. Weak lateral alar cartilages can result in their collapse when breathing in. This can often occur after a rhinoplasty when too much cartilage has been taken due to an aggressive cephalic trim.

Support to the lateral alar can be done with cartilage, known as batten grafts. As the name implies a batten graft provides support to either help the collapsed lateral alar cartilages be brought back out as in a secondary rhinoplasty or as a preventative maneuver to prevent potential collapse after surgery in a primary rhinoplasty. The most common batten grafts comes from the septum since it is straight and fairly strong. But when a rib graft is being harvested anyway, it can be cut into thin batten grafts that are even stronger than that from the septum. The stiffness of these grafts is best done in noses with thicker skin.

Dr. Barry Eppley

Indianapolis, Indiana

September 2nd, 2017

OR Snapshots – Vertical Ear Reduction with Scaphal Resection

 

Changing the shape of the ear is most commonly done by a traditional otoplasty or ‘ear pinning’. While the size of the ear may seem to get a bit smaller in otoplasty as it moves the ear closer to the side of the head, the actual ear size does not really change.

True ear size reduction involves a vertical change in the length of the ear from the superior helix down to the bottom of the earlobe. The most recognized ear reduction procedure is that of earlobe modification. The earlobe can be reduced by a variety of techniques but, regardless of which method is used, they all create some reduction in its vertical length as all large earlobes hang too low.

The most dramatic way to reduce a large ear is to cut out a portion off its middle, bringing the upper and lower thirds of the ear closer together. But the scar that is created by doing so would be aesthetically unacceptable and such ear reductions are only usually done in skin cancer resections.

The often overlooked or unknown ear reduction technique involves that of the upper third of the ear. Known as a scaphal flap reduction technique, skin and cartilage are removed from inside the helical rim above the antihelix and superior crus. There is a backlit across the helical rim at the middle portion of the ear which controls the amount of vertical ear height reduction. This is also the only location of a visible scar.

While often combined with ear reduction for maximal ears height reduction as in macrotia reduction surgery, the scaphal flap reduction technique can be done alone if the earlobe is already small enough. Int its use it is important to remember that its effect is in reducing the size of the upper third of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

September 2nd, 2017

OR Snapshots – Transpalpebral Brow Bone Reduction

 

Brow bone reduction surgery reduces the prominence of the supraorbital ridges of the forehead and can be done in both men and women. Whether done for males to reduce the ‘Neanderthal’ brow or in male to female transgender facial feminization procedures, the main direction of reduction is in the horizontal dimension. Reducing the brow bone prominence generally means reducing its projection.

But horizontal brow bone reduction is not the only dimension of the brows that can be changed…or may need changed based on the patient’s aesthetic desires. Brow bones can also be reduced vertically to increase the orbital aperture and give the eyes a more open look or reduce a heavy appearance.

While both horizontal and vertical brow bone reduction can be done through a long coronal scalp incision, a purely vertical reduction of the bone does not need to be done so. It can be done through an upper eyelid incision (transpalpebral approach) which provides a direct and short route to the lower edge of the brow bone.Using a handpiece and burr the brow bone edge can be raised 5 to 7mms if desired from side to side. It also can be reduced horizontally if desired on the outer 2/3s of the brow bone.

The transpalpebral approach is an often overlooked method for brow bone reduction. While it does not provide enough access for the more significant osteoblastic flap reduction technique and is limited for central or glabellar reductions, it does provide direct visual access to the tail of the brow bone where burring reduction can be done. It is an excellent technique for secondary or revisional brow bone procedures and can be used for primary reductions that need changes in the outer half of the brow bone only.

Dr. Barry Eppley

Indianapolis, Indiana

September 2nd, 2017

OR Snapshots – Lingual Frenuloplasty

 

Being tongue-tied is a common phrase that implies one can not speak due to a loss of words. But being tongue-tied is also a real medical condition that is a well known congenital oral defect known as ankyloglossia. It occurs when the attachment of the tongue (lingual frenulum)) is unnaturally short.

The lingual frenum is a web of mucous membrane that connects the underside of the tongue to the front of the floor of the mouth at the locations of Wharton’s ducts. During fetal development the lingual frenum serves to keep the tongue fixed into position as it grows forward as the oral structures around it form. If some abnormality of the frenum occurs during this process, the frenum remains short and its lack of adequate length is evident at birth. Very short frenulum attachments can cause numerous functional problems with speech, feeding and oral hygiene/function.

Surgical release of short lingual frenum is known as a frenoplasty. There are debates as to when this procedure should be done if needed. But when it is done the technique of doing it remains the same. In infants and children the procedure is done under a limited general anesthetic. The frenum is incised with a needlepoint electrocautery at its tightest point on the underside of the tongue. With the tongue on stretch, the release is performed until the tip of the tongue can be brought well past the incisal edges of the lower teeth. This v-shaped release is then closed as a linear line with an elongated undersurface of the tongue with small resorbable sutures.

The lingual frenuloplasty is an uncomplicated procedure that its highly effective and has a short operative time. Its only potential complications are disruption of the salivary ducts or the lingual veins, both of which are easily avoided.

Dr. Barry Eppley

Indianapolis, Indiana

August 28th, 2017

The Three Types of Infraorbital Rim Implants

 

The undereye area has become a focus of aesthetic attention for the management of tear troughs and hollows. Some of these occur as a result of aging and others have a more congenital origin which then becomes more apparent with aging. Treatment for aesthetic under eye issues is fundamentally about adding volume. Injectable fillers and fat are the mainstays of this volume addition with the adjunctive use of lower blepharoplasty skin removal if needed.

While the injectable management of undereye contour issues cam be very effective, it does not work well for some patients. It is particularly ineffective for true infraorbital bone underdevelopment which is associated with a negative orbital vector. In these cases an infraorbital rim bone augmentation using an implant would be best. While a surgical procedure it provides permanent smooth rim augmentation whose volume retention is assured.

Infraorbital implants is an uncommon facial implant and, as a result, the differences in the style options is rarely appreciated. They come in three styles, one performed and the other custom made. Most surgeons are aware of tear trough implants or what I call type 1 infraorbital rim implants. These are preformed implants that comes in three basic sizes, differing largely in their  These are designed to fit on the front edge of the infraorbital rim and provide horizontal projection. The do effectively improve the classic tear trough deformity at the medial orbital rim by a release of the arcus marginalis and the addition of volume. But they do not provide any vertical rim augmentation and do not extend out into the malar region. Attempts at trying put their upper edge above the level of the existing infraorbital rim bone will result in a palpable and potential visible edge in the thin tissues of the lower eyelid.

The type 2 infraorbital rim implant covers both the infraorbital rim and extends out onto the cheek. It provides a vertical as well as a horizontal rim augmentation effect and extends from close to the nasal bones medially out onto differing locations in the cheek laterally. It is custom made so a wide range of dimensions and surface area coverage are possible based on the aesthetic needs of the patient. It is the ideal design for augmenting an infraorbital rim bony deficiency as there is always associated cheek flatness as well. As a result it creates a smooth and harmonious flow of augmentation across this very visible facial region.

Custom infraorbital rim implants can also be made to just cover the infraorbital rim area only, providing vertical rim augmentation. (type 3 infraorbital rim implant) This is the least commonly used type of infraorbital rim implant. Such isolated vertical augmentation could only be effectively done in a custom made process.

Augmentation of the infraorbital rim area can not be accomplished with a single implant style for the range of anatomic deformities that occur and to achieve satisfactory aesthetic outcomes. Understanding the differing options of this unique facial implant can be a good complement to injectable treatment strategies.

Dr. Barry Eppley

Indianapolis, Indiana

August 28th, 2017

Female Jawline Augmentation in the Aging Face

 

Jawline augmentation has traditionally been thought of as male procedure. Envisioning a defined and strong jawline is a well known facial feature that has historically implied masculinity and a strong personality. But in today’s world a good jawline is no longer gender specific. Many women of all ages (although more so in younger than older women) now seek jawline enhancement. Undoubtably driven by jawline shapes of well known celebrities and models, and the strong influence of social media as well, female jawline augmentation is an emerging aesthetic facial surgery procedure.

Regardless of whether it is a male or female, one benefit not often appreciated about a stronger jawline is the structural support that it provides to the soft tissues of the lower face at any age. This can be seen in jaw angle reduction surgery where some patients complain of the soft tissue sagging that occurs when the jaw angles are removed. Restoring or augmenting the jawline shape lifts up loose or sagging tissues which are obtained from the neck rather than that of the face. (in other words tissues are pulled up not down in jawline augmentation)

While jawline augmentation provides definition to the younger jawline, an often overlooked benefit is what it can do in the older jawline. With the descent of facial tissues over the jawline with aging (jowling), a jawline implant can help smooth out these soft tissue redundancies. Depending upon the amount of jawline and neck sag, a jawline implant can be done alone or in conjunction with some form a lower facelift.

In the thin older female with jowling and a mildly weaker jawline, a thin jawline implant can be very effective. It does not provide any jaw angle width augmentation as it stops short of the jaw angle region. It provides chin and jawline definition and in many ways is a jawline extender. Such a long but thin implant can be inserted through a submental incision or even intraorally.

In the female facelift patient such an implant should be considered. While once managed by a chin-prejowl implant placed at the same time, a more contemporary approach employs this more complete jawline augmentation approach.

Dr. Barry Eppley

Indianapolis, Indiana

August 26th, 2017

Subcostal Rib Removal Through a Tummy Tuck Approach

 

The ribs constitute the structural support for the trunk. It plays a vital role in how the lungs work and in the support and protection of many other vital organs. This statement applies to much of the upper ribcage but does not necessarily apply to every aspect of every rib throughout their full lengths around the chest and abdomen. As such, there is some latitude to remove or reduce selective rib areas for body contouring effects.

Rib removal, or what I prefer to call ribcage modification surgery, is most commonly associated with waistline reduction. This is specifically horizontal waistline reduction. This is accomplished by removal of the outer half of the posterior ribs 11 and 12 and sometimes part of rib 10 as well. But this is not the only rib area which can be modified.

On the front or anterior surface is the subcostal portion of the ribcage. This rib area is distinctly different from that of the back for reasons that are different than just body location alone. The subcostal rib cage is cartilaginous and not bony. It can cause aesthetic distraction by either having too much protrusion due to a bowing of the ribs or sits low causing a short vertical waistline. Like the lower ribs on the back, subcostal rib removal can also be done to reduce a bulge in the upper abdomen/lower chest wall or to vertically lengthen the waistline.

Subcostal rib removal can be done through either a direct incision over them or from below through a tummy tuck incision. Each approach has its own advantages and disadvantages. The direct incision, even though relatively small, still leaves a scar in a non-hidden area. It limits the zone of tissue trauma by dissecting directly down to it. But it remains for the highly motivated patient.

The other approach to subcostal rib reduction is through a tummy tuck incision. In theory this should be reserved for patients that are already having or want abdominal work…but this does not need to be the case. It can be done in patients who do not necessarily need a tummy tuck as a longer lower abdominal scar may be preferable to two smaller subcostal scars. The distance to the subcostal ribs is easier to access when a full tummy tuck is performed as the upper edge of the abdominal skin flap is closer to the target than when no lower abdominal tissue is removed.

Since the subcostal ribs are cartilage and not bone, they do not have to always be excised completely. They can be shaved down with a large scalp blade for reductions in their protrusions. The ribs can be made quite thin by sequential shaving reductions where they also become more flexible/weaker which has an additional effect on protrusion reduction.

Subcostal rib reduction is more challenging than posterior rib reduction due to scar considerations from the incisional access. Both the direct and tummy tuck approaches can be used to perform it. The effectiveness of either approach in reducing subcostal protrusions is the same.

Dr. Barry Eppley

Indianapolis, Indiana

August 26th, 2017

Computer-Designed Synthetic Framework in Ear Reconstruction

 

Reconstruction of lost or congenitally malformed ears requires the combination of a solid framework and soft tissue coverage of it. Two techniques for making a framework for the ear have been developed over the years. By history and still commonly used today is to make the framework by harvesting and assembling rib cartilage grafts. While technically challenging to successfully create the intricate topography of the ear, its autologous composition offers a hardy framework that is very durable over time and has a very low risk of any complications long-term. It also can be placed under the existing skin over the implantation site if it is of good quality.

The other ear reconstruction technique is to use a premade synthetic framework. This creates the best shape of the ear, shortens the operative time and avoids a rib graft harvest scar and its associated discomfort. But it can not just be placed under the natural thin skin of the ear. It requires a vascularized tissue cover, using a pedicled temporalis flap turned down from above to cover the synthetic framework, which is then covered by a skin graft. This requires two donor sites from the temporal scalp (fascial flap) as well as the thigh. (skin graft)  Adequate soft tissue cover is of paramount importance to avoid the risks of implant exposure and infection both short and long-term.

The traditional ear synthetic framework is that of porous polyethylene or Medpor. It comes in a variety of implant shapes and parts to be assembled during surgery based on the size and shape of the opposite normal ear. While creating acceptable results, this assembly approach never creates a prefect match to the opposite ear.

To improve the matching of a synthetic framework to the opposite ear, I have been using a computer-designed ear reconstruction frameworks. From a 3D CT scan of the patient, an exact replica of the cartilage framework of the opposite ear is mirrored onto the missing side. This computer design is then turned into a synthetic ear framework made of a composite silicone base with an ePTFE coating.

This ePTFE ear implant, in addition to having the best size and shape match possible to the opposite ear, also has one other very favorable characteristic. It is soft and flexible like natural ear cartilage (other synthetic frameworks are very rigid and unnatural feeling)  and as a result can well tolerate any trauma to the ear.

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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