Plastic Surgery
Dr. Barry Eppley

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

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

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

December 26th, 2017

Technical Strategies – The Synergist Effects of Wedge Latissimus Muscle Removal and Rib Removal on Waistline Reduction


Rib removal offers the elimination of the last anatomic obstruction to narrowing one’s waistline. This procedure creates its effectiveness through the removal of the inner bony component of waistline support. The free floating ribs, unlike the ribs above it, have an almost vertical orientation downward with only soft tissue attachments at their small cartilaginous tips. This is why one can push in on their waistline and feel the length of these ribs. Removal of the outer half of the ribs (there is no reason to remove them back to the vertebral facets) allows the soft tissue to move further inward this narrowing the waistline.

But between the skin and the lower free floating ribs lies other tissues which must be traversed. The biggest structure between the skin and these ribs is the latissimus doors (LD) muscle. Known as the ‘lats’, this is the broadest muscle on the back that extends form the upper arm down to the spine and the iliac crest. While the thickness of the muscle does thin at its most inferior extent over the lower ribs, it is still amazing how thick it still is in the lower back region. It is always at least 1cm thick and often as much as 2 cos.

One technique to improve rib removal results is to resect a wedge from the LD muscle in the lower back along the horizontal waistline area on both sides. By so doing the waistline reduction is further enhanced by the thickness of the muscle removed. This can add up to an inch improvement in the results.

Removal of a wedge of the LD muscle does not cause any functional deficits since the spinal insertion of the main body of the muscle remains intact. This wedge preserves the side to side integrity of the muscle.

Dr. Barry Eppley

Indianapolis, Indiana

December 25th, 2017

Rejuvenation of the Hollow Upper Eyelid with Fat Grafting


Loss of fat in the upper eyelid creates a hollowing which is commonly associated with an unaesthetic appearance. This creates a concavity or depression in the upper eyelid that results in a shadow. With this eyelid inversion or A-pattern more of the curvature of the eyeball and pretrial skin is exposed. In the side view this creates a distinct concave appearance. All together this absence of upper eyelid fat creates a more gaunt or aging upper eye appearance.

Volumetric restoration or augmentation of the upper eyelid requires the placement of fat. While fat grafting has been widely used all over the face, there is no consensus for how it should be done in the upper eyelid. Techniques vary widely from an open or closed approach and which plane in which to place the fat grafts.

In the November 2017 issue of the journal of Plastic and Reconstructive Surgery an article was published entitled ‘Fat Grafting in Hollow Upper Eyelids and Volumetic Upper Blepharoplasty’. In this paper the authors review their experience in thirty-two (32) women who had fat grafting to the upper eyelids over a four year period. The majority of these involved skin resection (26) with the remaining minority being augmentative only. (6) The term ‘volumetric upper blepharoplasty’ refers to a dual plane fat graft placement combined with orbicularis muscle imbrication. The average amount of injected fat grafting was 0.4cc in the deep plane (concave depression below the supraorbital rim) and 2.8cc in the superficial plane. (1mm over the eyebrow to a line 10mm above the ciliary margin) If skin for an upper blepharoplasty is to be removed it is secondarily done with the consideration of the tension that will be placed on the closure by the fat grafts. In each patient treated the inverted ratio was adequately corrected in the front view. In the side view the concave shape was converted into a convex one, regardless of the technique used. No infections were seen nor was any revision procedure done. Some far graft loss was seen in six patients but it did to affect their results.

Volumetric upper blepharoplasty is primarily a fat grafting technique in which any skin resection is complementary. The goals of fat grafting and the muscle plication is to increase the muscle volume. The skin resection serves to smooth out the upper eyelid and lower the supratarsal crease. This technique is really a paradigm shift in how upper blepharplasty can be performed although its application is to the subset of patients who have upper eye hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

December 25th, 2017

Case Study – Otoplasty Surgery for Ear Reshaping


Background: The protruding ear stands out from the side of head in an exaggerated fashion which is what makes it too visible. One of the features of a good looking ear is that it does not stand out in any conspicuous way. The increased auriculocephalic angle of the protruding ear is not due to a cartilage deficiency in volume. Rather the ear has a normal amount of cartilage but it just does not have the right shape.

Reshaping of the protruding ear through otoplasty surgery involves a variety of cartilage manipulation techniques. One of these and the one that is inherent in about every such ear surgery is the creation of a more defined antihelical fold. This is a natural fold in the ear that is the secondary cartilage fold that sits just inside the outer helical fold. Its relevance to the protruding ear is that when this fold of ear cartilage is absent or ill-defined the outer edge of the ear sticks out further.

While the results from otoplasty surgery for the protruding ear are always shown from the front or back view, it is also important to consider what the ear looks like from the side view. This has relevance during surgery as if an overcorrection occurs it can also be appreciated by an inadequate lengthening of the ear from front to back. (tragus to outer helix)

Case Study: This young female had ears that stuck out due exclusively to the absence of an antihelical fold of cartilage. Under general anesthesia an otoplasty procedure was performed from an incision on the back of the ears. Permanent horizontal mattress mattress sutures were used to create a more defined antihelical fold which pulled the ears in closer to the side of the head.

As the ear is pulled back further inward to the sides of the head by helical rim repositioning, the length of the ear from front to back (tragus to helical rim) increases. This anteroposterior ear change should look natural and not ‘scrunched’ which is a sign of over correction.


1) Traditional otoplasty surgery is about reducing the protrusion of the ear as seen in the frontal view.

2) Most reshaping procedures for the protruding ear involves creating a more defined anti helical fold.

3) The side view of the reshaped ear in otoplasty shows an increased length of the ear from front to back.

Dr. Barry Eppley

Indianapolis, Indiana

December 25th, 2017

Case Study -Breast Implants for Improved Mound Shape and Asymmetry Correction


Background: The primary goal of breast implants for every patient is an increase in breast size. Such an effect is always achieved as one would expect from placing a permanent implant into the breast mound. But some women also desire that they have a breast lifting effect which is not nearly as predictable or should even be expected in most patients.

It is commonly stated that all breast implants do is take the existing shape of the breast and make it bigger. And this is certainly true when it comes to the shape of the breast. If one has a good mound with tight skin and a centered nipple then a very pleasing shape will occur afterwards. If one has a saggy breast with a low nipple position, breast implants will usually not create an improved shape and may well make the undesired shape more so albeit wth a bigger breast mound.

Case Study: This young female wanted a modest increase in her breast size. She wanted  a full B or small C cup size. She has tight breast skin with a short nipple to inframammary fold distance. This made her nipples point slightly downward. In addition she had asymmetry with the left breast mound being slightly smaller and with a lower nipple position.

Under general anesthesia she had high profile round smooth 300cc silicone breast implants placed in a dual plane position through small 3.5cm inframammary incisions. The implants were inserted using a funnel device.

Despite her small and tight breast mounds with asymmetry, her after surgery results showed improved symmetry and better shaped breast mounds. This effect is caused primarily by the influence of the increase in the fullness of the lower breast pole which is where two-thirds of the influence of the implants occur. If the skin is tight enough and the nipple position is still above the fold, no matter how slight, the effect of the implants will create a minor breast lifting effect.


1) Breast implants create a volumizing effect which may have a lifting effect.

2) The lifting effect of implants come from filling out the lower pole of the breast which drives the nipple forward and up.

3) The tightness of the breast skin and the size of the implant will determine whether a breast lifting effect is achieved.

Dr. Barry Eppley

Indianapolis, Indiana

December 24th, 2017

Fat Grafting for Chin Augmentation


Chin augmentation is one of the most facial augmentation procedures, both historically and to the present day. Chin implants are the most common method to achieve these changes and they are more successful than not in the vast majority of patients. Injectable methods of chin augmentation have come into play since the introduction of synthetic temporal fillers. Such fillers can be used as a temporary test of the effects of chin augmentation.

Fat injection grafting is the most popular method of soft tissue augmentation anywhere on the body today. Its use for hard tissue augmentation in the face, however, has been more limited with its most extensive use for cheek augmentation. Although injectable fat grafting has clearly been used all over the face but with limited critical analysis of its effectiveness.

In the December 2017 issue of the journal of Plastic and Reconstructive Surgery an article was published entitled ‘Prospective Controlled Study of Chin Augmentation by Means of Fat Grafting’. In this paper the authors evaluated forty-two (42) consecutive cases of chin augmentation by fat grafting over an 18 month period. A three-dimensional analysis was done to determine volume and gain in sagittal projection. All patients showed an increase in both sagittal projection and in total volume at one  and six months after surgery. There was an average increase of almost 9mm in sagittal projection and with an average volume of almost 8mls.

It is no surprise that injectable fat grafting can be used for chin augmentation. Like just about anywhere else on the face, fat grafting has been shown to be capable of graft take. But it is important to remember that this is a biologic graft and not an implant. While a six month result for an implant used for chin augmentation would give a good gauge as to its outcome, the same can not be said for a fat graft. Does it persistent or two years later? How does it respond to weight gain and weight loss? What happens if the patient does not like the result and wants it removed later?

Like all chin augmentation methods, each one has its advantages and disadvantages. No singe method is perfect and the patient must accept their tradeoffs. The long-term outcome of fat grafting to the chin as yet remains unknown.

Dr. Barry Eppley

Indianapolis, Indiana

December 24th, 2017

The Posterior Zygomatic Arch Osteotomy in Cheekbone Reduction (Facial Width Reduction)


The cheekbone occupies a significant part of the midface. It is responsible for the projection and width of the side of the face. The name of the bone, the zygomatic-orbital complex, speaks for the main body of bone and the legs of bone that extend underneath the eye, down onto the maxilla and back towards the ear where it meets with the temporal bone.

The least appreciated part of the cheekbone is the zygomatic arch. This thin leg of bone is shaped so the thick temporals muscle can go underneath it to attach to the lower jaw. This creates a convexity of the bone that is primarily responsible for the width of the side of the midface. Despite this long thin section of the cheekbone, it has a major influence on the width of the face. This is why one type of cheekbone reduction surgery consists of moving this part of the cheekbone inward to create a narrowing effect. Through osteotomies of the front and back end of the zygmatic arch, it is moved inward and secured with small plates and screws. This reduces the convexity of the arch and thus the width of the face.

In some concerns about facial width only part of the zygomatic arch is implicated. Some patients are bothered with their excessive facial width back closer to the ear or back part of the zygomatic arch. In these cases an isolated osteotomy can be done on the posterior zygomatic arch just anterior to where it attaches to the temporal bone. This is. approached through a skin incision one the back side of the sideburn hair. The bone is cut and pushed inward and fixed with a 1.5mm step plate. Even though the front part of the zygomatic arch is not cut, the back of the arch can still be bent inward.

3D CT scans show that inward position of the posterior zygomatic arch, reducing the posterior width of the midface. At 5mms per side the bifacial width can be reduced by 1 cm. Further inward movement can be obtained by partial osteotomies of the anterior attachment of the zygomatic arches. (almost a more complete cheekbone reduction approach)

Dr. Barry Eppley

Indianapolis, Indiana

December 24th, 2017

Case Study – Knee Lifts for Excessive Skin Rolls


Background: The descent of gravity affects many face and body structures. The lower extremities are no exception. One of the leg places that tissue falls to is the knee. The knee acts like a stop for tissue descent due to the rigid attachments of the knee joint. It tends to ‘pile up’ above the patella also known as the kneecap. The broader upper surface of the kneecap and its attachments acts is where lower thigh tissues come to rest when the leg is extended.

Problematic knee rolls can not really be improved without direct excision. Any form of a thigh provides a tissue pull that is too distant. Even it were effective many patients with knees rolls do not need or want a thigh lift. The most common treatment approach for knee rolls is liposuction. Besides being ineffective it often, however, makes the knee rolls worse with the tissue deflation. Such knee skin does not have the ability to contract and become less with subcutaneous fat removal.

The knee lift is an uncommon procedure even though it is very effective at removing the knee rolls. The cancer with its use is the obvious visible scar concern. Since the knee must bend such a scar raises the additional concern that it will widen and become an equal aesthetic distraction as the knee rolls themselves.

Case Study: This middle-aged female was bothered by the multiple skin rolls above her knees. Three to four rolls of skin encroached and hung over the top half of her patella with the leg in extension.

Preoperative markings for knee lifts must be done in both leg extension and flexion. Flexion will expand the crescent-shaped skin markings from that done in extension. This shows how much much more tension would be placed on any tissue excision done with the leg extended. The skin marking must then be reduced from what was marked in extension. Usually it will be about 2/3s for what was originally marked in extension to avoid the risk of postoperative wound separation when the knee is bent.

Under general anesthesia the crescent-shape tissue excision is done, removing the upper two-thirds of the preoperative markings. This ensures that the final closure line rests above the patella as well as avoids over resection. The tissue excision only goes down the subcutaneous fat level and stops short of the fascia. A two-layer closure is done with subcuticular skin suturing.

Knee lifts can be a successful treatment for  excessive skin rolls with very acceptable scarring. The key is proper scar line placement and avoiding over resection of tissue. this is dependent on preoperative markings with the knee in both extension and flexion and making the necessary adjustments.


1) Saggy knees develop a roll(s) of skin above the patella.

2) No form of a thigh lift can improve the distant knee location.

3) Knee lifts remove skin and subcutaneous fat above the knee which must be marked carefully to avoid over resection of tissue.

Dr. Barry Eppley

Indianapolis, Indiana

December 24th, 2017

Fat Grafting and World War 1


It has been said that many techniques used in plastic surgery, both reconstructive and cosmetic procedures, have their origin in war. The need to develop methods to treat devastating injuries of the face and body serves as the basis for innovation. This is best known in the development of many plastic surgery procedures of the face where World War 1 thrust surgeons of the day into a whole new world of missing parts of the face from trench warfare. Not only techniques but the surgeons that developed them live in the chronicled history of plastic surgery…long before plastic surgery was they established surgical discipline that it is today.

In the November 2017 issue of the Annals of Plastic Surgery an article was published entitled ‘Use of Fat Grafts in Facial Reconstruction on the Wounded Soldiers From the First World War (WWI) by Hippolyte Morestin (1869–1919)’ This pioneering French surgeon’s work during the Great War from 1914 to 1918 was on the large numbers of facial injuries that this conflict created. As head of a surgery department that specialized in the face, he developed numerous techniques using tissues from the patient’s own body to fill tissue defects in facial reconstruction. This paper focuses primarily on the fat grafting techniques and their aesthetic outcome used by Morestin during World War I. (he died one year after the end of the war)

Using documents and pictures from the archives of the Val-de-Grace Army Health Service, thirty-four cases published by Hippolyte Morestin dealing with facial reconstruction during the World War I were studied. Free en bloc fat grafts were used to fill craniofacial defects. While most of the grafts were harvested from the patient, fat grafts from other people were sometimes used. The goal of the surgery was to create more volume but benefits were also seen in improved skin healing and skin flexibility.

While done in a time before antibiotics and field and instrument sterilization were not developed, it is amazing that such tissue grafting worked at all. But its success then served as the yet unknown foundation for the fat grafting procedures done in plastic surgery today. While the exact reason why fat grafting works (and sometimes does not work) is not completely understood today, it is believed that other elements in the tissue (e.g., stem cells) are favorable for healing and cellular regeneration. While it was innovative over one hundred years ago to just graft tissue from one part of the body to the other and have some of it live, its application today in both reconstructive and cosmetic procedures is no less impressive.

For me the greatest relevance in Morestin’s work is the use of enbloc fat grafts. (not liposuction harvested and injected fat as is most commonly used today) Such fat grafts still have application today and I frequently use them in the form of dermal-fat grafts for small to modest face and body defects. While not talked or written about much today they still are a valuable tissue grafting technique which was really what was done in fat grafting in the first three-quarter’s of the last century.

Dr. Barry Eppley

Indianapolis, Indiana

December 23rd, 2017

Technical Strategies – Frontal Sinus Obliteration Brow Bone Reduction


Brow bone reduction is a forehead reshaping procedure for both men and women. In men it is done to reduce an overly prominent brow bone appearance but yet maintain some accepted male brow bone presence. This almost always requires a setback bone flap technique. In some women it may be done to soften the brows and a successful result may come from a bone burring technique only.

In transgender male to female brow bone reduction, however, the goal is more aggressive with the objective of a complete elimination of any brow bone protrusion at all.  In making a male brow bone shape into a female appearance, the ultimate success is what happens at the frontonasal angle area. Inadequate reduction in this area mars many male to female conversions with a residual high radix and a very open nasofrontal angle. This fails to create a visible lessening of the frontonasal angle that is closer to the projection of the eye. This is the result of inadequate bone reduction at the lower end of brow bone just above the frontonasal angle. It also is contributed to by inadequate reduction of the height of the nasal bones which creates the lower line of this angle.

Getting the brow bone flap set back far enough can almost always be done by bone manipulation (reduction) alone. With the bone flap removed the height of the frontonasal angle can be directly reduced by burring before putting the bone flap back. But when this method fails or a patient desires maximal brow bone reduction beyond what a bone flap technique will allow, there is an alternative strategy.

Maximal reduction of the brow bones and height of the frontonasal angle can be done by a frontal sinus obliteration technique. In this method the brow bone flap is removed and not put back. Rather the frontal sinus lining is removed, the bone flap used to graft the frontonasal ducts and hydroxyapatite cement placed to fill in/obliterate the complete frontal sinus cavities. This removes the last bony obstruction for maximal setback and opening up of the frontonasal angle.

In this frontal sinus obliteration technique it is important to later in the hydroxyapatite cement and compressed packing to be sure all air spaces of the sinus are completely filled.

Frontal sinus obliteration is not a standard technique in brow bone reduction and is usually only used in the rare event of chronic frontal sinusitis/bone flap osteomyelitis. But when maximal brow bone reduction is desired or as a secondary reduction method when the first is inadequate, it offers a highly effective reduction contouring method.

Dr. Barry Eppley

Indianapolis, Indiana

December 23rd, 2017

Guidelines for Reducing Major Complications in Liposuction


Liposuction remains the most common cosmetic body contouring procedure, both in terms of numbers of patients and body areas treated. While the overwhelming numbers of patients who undergo the procedure do well, there is always the risk of an adverse medical event. The invasive nature of the procedure with instrument introduction and the infusion of large amounts of fluid and tissue extraction make for traumatized internal tissues over an often large body surface area. This is what makes it truly unique from almost all other body contouring operations.

Death and major medical problems from liposuction are very rare. Patients understandably are very concerned about these possibilities and such few adverse events give liposuction a notoriety that no other plastic surgery procedure has. The risk of death for liposuction in some studies has been quoted as 1 in 5,000. (0.0002%) While this statistically seems very low, such a number for a cosmetic procedure seems high. What are these specific major medical events and how can they be prevented?

In the October 2017 Global Open edition of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Strategies for Reducing Fatal Complications in Liposuction’. The authors conducted a literature review based on a search cross-indexing the terms Liposuction, Major Complications ad Death from which 39 articles were found to evaluate. They found five serious complications from liposuction including  thromboembolic disease, far emboli, pulmonary edema, lidocaine toxicity and intra-abdominal violation.

Pulmonary embolism is the most common cause of death in liposuction. Its prevention comes down to assessing the risk of deep vein thrombosis (DVT) in the patient for which the Caprini scale is the most widely used preoperative assessment. For those patients at higher risk by this assessment scale (3 or higher) , the use of high-molecular weight heparin begun 12 hours after surgery and continued for up to ten days after surgery is one proven chemoprophylaxis treatment.

Bowel perforation by the cannula violating the abdominal wall is the one potential lethal mechanical injury. While largely technique related, patients with abdominal wall defects from prior surgeries and unrepaired/repaired hernias are recognized preoperative risks. While all patients undergoing abdominal liposuction will have abdominal pain afterwards, suspicion must be high for this possibility of such pain seems unusually different. Very early intervention for the treatment of bowel perforations can prevent major sepsis and death.

The large infiltration of fluids (Hunstad solutions) immediately prior to liposuction creates the risk of too much fluid given (potentially causing pulmonary edema) and/or causing side effects from the medications in the introduced fluid. (lidocaine and epinephrine) To avoid fluid overload the ratio of infused fluids to the total liposuction aspirate should be considered. This ratio consists of replacing just under 2mls per cc of liposuction aspirate liposuction volumes of under 5,000 cc and closer to 1 ml per cc for liposuction volume greater than 5,000 ccs.

The lidocaine in tumescent liposuction solutions runs the risk of creating systemic toxicity. Since the peak plasma concentration of lidocaine does not occurs for a long time after surgery (8 to 10 hours) due to the effects if epinephrine, any toxic side effects will often only occur when the patients is beyond monitored medical care. The historic guideline for lidocaine dosing is 7mg/kg when used with epinephrine but studies have shown that concentrations between 35 and 55?mg/kg can be used safely in liposuction infusions.

Epinephrine is used in liposuction solutions to decrease bleeding and prolong the effects of the lidocaine for local anesthesia purposes. It is standard practice to use 1mg of epinephrine for each 1 liter of infused solution. (up to 10mg total dosing) Epinephrine levels during liposuction peak a few hours after infusion and their plasma levels often triple what normally occurs. Thus patients who may be at risk for epinephrine sensitivity or the development of cardiac events should have preoperative cardiac evaluation.

Small fat emboli from liposuction are not rare and has been reported to occur in almost 10% of the patients having the procedure. (although most do not cause a problem) A fat macroemboli is where a fragment of tissue has been introduced inside a vein which is then carried back towards the lung via the vena cava causing a potential thromboembolism due to mechanical obstruction. This risk is greatest when liposuction is done to harvest tissue for at injections of the buttock regions. Since almost all liposuction procedures of any quantity create a lipid macroglobulinemia there is always the risk for causing fat emboli syndrome. This syndrome occurs due to vessel irritation from fat microemboli in the blood stream whose risk is increased in low intravascular fluid volumes. Adequate fluid hydration is the known preventative measure.

One method to reduce most of these risks in liposuction is to limit the fat volume extracted. While this runs contrary to what the patient ideally wants and for the buttocks augmentation procedures where maximal extracted fat is usually needed, keeping the aspirated volumes to 5 liters or less helps reduce risks of fluid overload and pharmacologic toxicities.

This paper provides an excellent overview of the known practices that help reduce the risk of major complications in liposuction of the body.

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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