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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.

November 4th, 2017

The Osteoplastic Bone Flap Technique in Brow Bone Reduction Surgery

 

Brow bone reduction is done for a variety of reasons in both men and women. While the primary objective is to reduce an overlying prominent brow protrusion, there are differences in why it is done and the technique used to achieve it. In men reduction of the brow bone is done to get rid of the Neanderthal’ look. In women a softening effect is needed to make the forehead more vertical from the brow upward. In the male to female transgender patient, the brow bone must be brought back and reshaped from the frontonasal junction out to the tail of the brow for a complete change in the periorbital appearance.

Brow brow reduction can be done by either a burring technique or actually cutting off the outer cortical bone and reshaping and moving it backwards. (osteoplastic bone flap setback) The differences between these two brow reshaping methods is more than just technique alone but in the amount of brow bone reduction achieved. Because a prominent brow is the reflection of how big the underlying front sinus is, burring can only reduce it by a subtotal thickness of the thin anterior table bone. This is usually less than 5mms and can often be only a few millimeters. Cutting out the bone and moving it back into the frontal sinus air space creates a far greater amount of brow protrusion reduction.

The osteoblastic bone flap setback technique must be done through either a hairline or coronal scalp incision. In some men with little to no hair coverage, a forehead horizontal wrinkle line can be used. But regardless of how one gets there the prominent outline of the frontal sinus can be seen and marked as the brow bone protrudes out prominently from the surrounding central forehead above the eyes.

A reciprocating saw is used to remove the anterior table of the frontal sinus at the level of the surrounding frontal bone from side to side. There will almost always be a vertical septum of bone that separates the two sides of the frontal sinus encountered underneath the bone flap that must be cut. The bone flap is then removed and the large frontal sinus cavity will be revealed underneath. The opening that goes down into the nose can easily seen which allows drainage of the sinus cavity. Unless there is chronic inflammation or mucocoeles in the frontal sinus there is no reason to remove it lining.

The bone flap is thinned out on both its under and outer sides to try and work out its convex shape. The bone is too thin to cut and reshape it unless one wants to use a lot of plates and screws to out it back together. Prior to its replacement back into the frontal sinus, the surround rim of bone of the frontal sinus is reduced particular across the inferior orbital rim and the frontonasal junction. This step is of critical importance as it is what allows the bone flap to be recessed back into the sinus without palpable step offs

The bone flap is placed back into position which should be further back into the frontal sinus cavity. It can be appreciated that the amount of brow bone reduction is a combination of the bone flap reset into the frontal sinus and the thinning of the bone flap by burring. The former is more important for the actual setback, the latter is more to make for a flatter outer brow bone shape. A single central low-profile bone plate is all that is needed for fixation. This should be for assured immobility and not to hold it out in space over the frontal sinus. The fit of the bone flap should primarily be against the midline bony septum with resting on much of surrounding bone edges. There will always be some open areas along the seams which can be covered by Surgical mesh or bone wax.

With an understanding of how the osteoblastic bone flap technique of brow bone reduction works, it is easy to see how it is far more effective than a burring reduction method. But if a complete brow bone reduction technique is needed, such as in facial feminization surgery, burring reduction is also needed to reshape the tail of the brow bone.

Dr. Barry Eppley

Indianapolis, Indiana

November 3rd, 2017

Case Study – A Standard Preformed Skull Implant for Female Crown Augmentation

 

Background: While skull surgery has been around for more than a century, such surgeries have been done for reconstructive reasons to replace missing portions or correct significant congenital skull shape deformities. Aesthetic skull surgery, however, is much more recent and consists of reducing prominent bony areas or improving its shape through augmentation materials. The use of custom implants made from the patient’s 3D CT scan is the most effective skull augmentation material today.

One of the more common aesthetic skull deformities that is treated by a custom implant is that of the crown. The crown refers to the area at the upper back of the skull. It begins at the point where the top of the head begins to curve downward to the back of the head and ends at a point just above the nuchal line of the occipital bone. It is semi-circular in shape.

A crown skull deficiency is a common female concern and is often manifest by hairstyle manipulations to camouflage a deficiency or in an effort to make a normal crown look even higher. The commonality of this head shape concern is evident in the commercial product known as a ‘Bumpit’ which serves as an external prosthetic means to make the hair on the crown area look higher or fuller.

Case Study: This young female had long been bothered by the flatness over the crown of her head. She was tired of teasing her hair up to improve the appearance of her head shape. While the crown area looked flat, one could put their hand on it and it felt like a large flat circular area. Because she lived in another country and could not obtain a 3D CT scan, a true custom skull implant could not be made. Instead, I used an implant design from my large custom skull implant catalog from other patient designs. The implant design chosen covered the area needed and had a central projection of 15mms. Given the the skull is a convex surface and the implant had some flexibility to it, it was presumed that it would have a good fit.

Under general anesthesia and in the prone position, a low horizontal occipital incision was made and a subperiosteal pocket developed up over and beyond the crown of her head. Sitting the implant on the patient’s head it could be seen that it had the right shape and projection where it was needed. Placing the implant showed a fit and degree of improvement like it was custom made for her. Even though the implant had multiple perfusion holes placed and its fit into the pocket was very tight, two microscrews were placed to ensure complete stability

While a custom made approach to implant fabrication for augmenting aesthetic flat skull contours is always ideal, certain types of skull augmentations may be able to be done with preformed skull implants. The crown of the head is one of the most amenable to this approach even that its surface area of coverage needed is fairly standard. The amount of implant thickness that the typical female scalp can stretch is also well known by experience and that is usually up to 15mms of central projection.

For those females that have a crown skull deficiency, this type of ‘bumpit’ implant that is performed may work well for their aesthetic needs. Not having to get a 3D CT scan and have a custom implant designed does lower the overall cost of the surgery.

Highlights:

  1. 1) One of the most common skull augmentations is in females who have a crown deficiency.
  2. 2) A custom skull implant is traditionally used in all large surface area skull augmentations.
  3. 3) Standard shaped and sized skull implants can be effective for crown skull augmentations which avoids the needs for a preoperative 3D CT and time needed for implant planning.

Dr. Barry Eppley

Indianapolis, Indiana

November 2nd, 2017

Combining Open Rhinoplasty and Subnasal Lip Lift

 

Patients desiring changes to the nose and reshaping of the upper lip are common. Nose changes are done by a variety of rhinoplasty techniques and lip changes accomplished by augmentations or surgical lifts. One of these uplifting lip procedures is the well known subnasal lip lift. Because it is done by an excision of tissue along the base of the nose, there has always been concerns about whether it should be performed with an open rhinoplasty or done separately.

When a rhinoplasty and a subnasal lip lift are done together, this traditionally places two incisions placed fairly close together. (one at the mid-columellar location and the other at the base of the columella. This potentially runs the risk of skin necrosis in the intervening small skin segment which exists between these two incisions. While I have personally never seen it, I know surgeons who have. That potential risk depends on what type of rhinoplasty is being done and how much dissection, if any, is done along the caudal septum and the anterior nasal spine. Even if no vascular compromise occurs, this operative combination results in two columellar incision whether it is done together or staged.

In the October 2017 issue of JAMA Facial Plastic Surgery Journal, a Surgical Pearl was published entitled ‘Combining Rhinoplasty with Upper Lip Lift Using a Single Line Incision’. In this paper the author describes his technique for combining two ‘nasal’ operations using a V-shaped incision located in the posterior third of the columella. This incision line then connects with the subnasal incision line. In the nasal sill area the flap extends about 3mms into the nose and then goes along the nasal alar crease laterally. The author describes a subnasal issue resection down to the anterior nasal spine and muscle plication sutures out laterally.

The use of a single base columellar incision location makes sense when the two procedures are combined. This certainly avoids any skin necrosis concerns but also potentially creates traction on nasal tip work due to the downward pull of the elevated upper lift. This would account for support sutures placed through the caudal septum to the central lip segment as well as muscle plication out laterally to prevent downward traction on the nose .

Dr. Barry Eppley

Indianapolis, Indiana

October 31st, 2017

Techniques in Knee Lifts

 

Many parts of the body suffer sagging or loose skin from the effects of aging and gravity. The tissues above moveable extremity joints (knees and elbows), however, has the added influence of motion across the joint with flexion to an arc of up to 120 degrees. As a result the stretching of the soft tissue over the bony joint contributes to loose skin and wrinkles when the extremity is extended.

Such an effect caused by gravity, aging and joint flexion affects the knee. Above the knee cap (patella) a crescent-shaped tissue redundancy can appear. This can be aesthetically disturbing in some women as the knee is very visible in shorts and many skirt styles. This suprapatellar mound of tissue have been treated by a variety of different modalities with very limited success. While liposuction can reduce its fullness this often only results in a deflated appearance and further tissue wrinkling/folds. In some patient it even makes its appearance worse. Non-surgical skin tightening devices and fat reduction methods offer limited to no visible improvement.

The knee lift is the only true effective procedure because it removes the excessive sagging tissues that abut up against the knee cap. The key to the procedure is carefully marking of the zone of excision and keeping the scar length and location as limited as possible. The suprapatellar excision must be marked both standing as well as sitting with the knees flexed at 90 degrees.This will ensure that an over resection is not done by a pinch test in flexion to determine the amount of potential tension on the wound closure.

The knee lift excision is taken down to the fascia in a wedge-like fashion leaving a layer of subcutaneous fat under the closure line. If this is not done the scar line can end up looking inverted in extension and even potentially in flexion. A layered subcuticular closure is done to avoid any external stitch marks.

While very effective the issue with the knee lift is the resultant scar and how well it heals. Most heal with a very fine line and an acceptable scar as the aesthetic tradeoff. But the risk of adverse scarring remains and the potential secondary need for a scar revision procedure.

Dr. Barry Eppley

Indianapolis, Indiana

October 30th, 2017

Techniques in Skull Reduction

 

The size of one’s head is most significantly influenced by the shape of the skull. While there are soft tissues that also envelope it, its size is a reflection of its overall dimensions and convexity. As a result, major reductions (1 cm or greater) in skull size or specific bony areas is not possible without creating a full-thickness bone defect.

But despite these bone thickness limitations, this does not mean that meaningful reduction in the skull can not be done. The skull has three layers very much like an Oreo cookie, an inner and outer cortical layer and a much thinner middle diploid space (marrow) layer. This can clearly be seen in standard skull x-rays.  It is the outer layer of the skull that can be reduced or roughly up to one-third of the skull’s thickness can be removed.

Outer table skull reduction is done by a bone burring technique. A high speed handpick with a fluted carbide burr can efficiently remove the outer table bone and transform it into bone dust. Over larger skull areas an effective approach is to create a grid pattern across the curved skull surface. By creating these 2 x 2 cm square islands of bone, it allows the proper depth to be placed just on the outer aspect of the diploid space and also ensures a more even level of bone removal. It is easy when reducing large skull surfaces to not be completely even at the depth of bone removal. So it is helpful to check oneself at regular intervals with smaller sections of bone reduction.

Because skull reduction is done right down to the diploid space, there is going to be some blood oozing from the bone (what I call ‘bone sweat’) right after surgery. For this reason the use of small drains for a day or to after surgery is needed to prevent any buildup of blood under the periosteum of the scalp. It also helps with lessening the amount of swelling and/or bruising that might find its ways down onto the face after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

October 29th, 2017

OR Snapshots – Injectable Diced Rib Graft Rhinoplasty

 

Cartilage grafting to the nose is most commonly done using anatomically convenient graft sites. This usually means the septum which offers straight graft dimensions or the ear which offer curved or shaped grafts. For many traditional rhinoplasty surgeries these graft sites are sufficient both in size and shape.

But in rhinoplasties that require larger amounts of augmentation, almost always that of the dorm, facial graft sites are too small in volume and do not have the right shape. This is where rib graft harvesting does into play if one wants avoid an implant or a cadaveric cartilage source.

While rib grafts in rhinoplasty offer plenty of volume, they usually have some shape issues. Occasionally a rib graft may actually be harvested that is straight or it can be carved to be straight. But rib graft carving must take into consideration the perichondrial lining and the ever present risk of postoperative warping.

A well known technique of avoiding rib graft warping in rhinoplasty is to change it from a solid graft to a particulated one. By dicing the rib graft into very small pieces or cubes and containing it in some form of a wrap, a very moldable cartilage graft is obtained. The debate in the use of diced rib grafts is whether it should be wrapped in autologous fascia, a very thin piece of allogeneic dermis or a bovine collagen mesh wrap (Surgicel) There is no standard consensus on the ideal wrap material.

Another method to place the diced rib cartilage graft is to not wrap it at all. The placement/containment method is a small syringe from which it can be injected. This requires a precise soft tissue pocket over the dorsum and can be done through either an open or closed rhinoplasty. The diced graft is injected and then digitally molded into the desired shape. Tapes and a metal splint are placed over it to help maintain its shape.

This injectable rhinoplasty technique allows for rapid tissue ingrowth into the diced cartilage graft. Within a few weeks it becomes very firm and maintains its shape. My and other clinical experiences show that significant graft resorption does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

October 29th, 2017

Case Study – Correction of Custom Chin Implant Malposition with Lag Screw Fixation

 

Background: Chin augmentation with implants has a long successfully history. While standard chin implants work for many patients, significant chin deformities do not fare as well. The shape and size of off-the-shelf implants are made for more modest to moderate aesthetic deficiencies primarily in the horizontal direction.

In the more severe horizontally deficient chin, which in many cases is really a manifestation of a mandibular growth deformity, the chin often has a dimensional deficiency that is not just in the forward dimension. As the ramus of the mandible fails to grow vertically long enough the jaw angles remain high and the mandibular body tilts downward. This creates a short but vertically long chin. Placing a standard implant on the front part of the chin will bring its projection forward and downward…not an ideal aesthetic change.  While the implant can be placed higher up on the front edge of the chin, this can create an exposed lower edge of the chin bone. This is why a sliding genioplasty is usually favored in this type of chin deformity as it can vertically shorten the chin  as it is brought forward.

Very horizontally short chins in females poses a unique challenge for implants.  Large chin implants have long extended wings which end up widening the chin significantly in the front view…an aesthetic problem that most women will find unacceptable. Women prefer more narrow chin widths and there are not standard implants that can offer enough projection but with a narrow base width.

Case Study: This female had a chin implant history of five previous surgeries over the years to find an acceptable chin augmentations result. She had a very short lower jaw, a class II malocclusion, and previous standard chin implants which were modified to try and give enough horizontal projection but not be overly wide. Her fifth and last surgery involved a custom chin implant made from a 3D CT scan. It had an uncommon design with a lot of horizontal projection, a narrow base and an almost cone-like shape.

She reported that this custom implant produced a satisfactory aesthetic change right after surgery. But with the first week after its placement, the chin shape changed and her chin become vertically long and lost its horizontal projection. She had a CT scan which showed that the implant had become displaced, basically falling of the chin and rotating 90 degrees. This gave her a ‘pharoah’s chin or false beard look.

Under general anesthesia and through her existing submittal incision, the displaced implant was removed through a thin overlying soft tissue coverage. A capsulectomy was done on the bone and releasing capsulotomies were done on the surrounding soft tissue pocket lining. The implant was reinserted and positioned as it was designed and secured with two 2.0mm screws through the implant into the bone. A capsular flap was raised from the inferior side of the soft tissue pocket and added as another tissue layer over the implant prior to skin closure.

Her immediate result showed how the chin was designed to look from the custom implant design.

Screw fixation of facial implants in general, and chin implants in particular, has often been debated. But it is important to remember that an implant over the front edge of the chin is not particularly stable. This can become more so based on the implant’s dimensions. While a custom chin implant ensures that the desired shape and size is achieved, there is no assurance it will stay where it is designed to be placed. In implants that look less positionally secure, double lag screw fixation ensures this will not be a postoperative problem. Repositioning of any chin implant malposition probably merits screw fixation to prevent recurrence.

Highlights:

1) A custom chin implant is as prone to malposition as a standard chin implant.

2) Any form of a chin implant completely falling off the chin bone is rare but in a high horizontal:vertical base ratio implant that risk is accentuated.

3) Screw fixation of chin implants prevents postoperative malpositioning and should be used in ‘high risk’ facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

October 27th, 2017

Product Reviews – Allofill Injectable Filler

 

Injectable fillers have evolved considerably since their introduction was back in 1981. While originally an xenogeneic collagen-based product, it has become largely populated by hyaluronic acid-based products. Given their synthetic origins, almost of current injectable fillers are temporary and have variable durations of volumetric effects. Despite new injectable fillers becoming available every year, they are merely variations of current product formulations.

Allofill represents a new injectable filler that is different on both composition and biologic effects. This is a ready-to-use allograft-derived filler that retains the natural extracellular matrix (ECM) of allogeneic-derived fat tissue. Human fat is decellularized to obtain a tissue scaffold that has biologically active components. This allows the body to grow into this matrix and populate it with the body’s own cells. In essence this is a form of injectable tissue engineering.

Allofill is made from cadaveric fat tissue and is used to fill soft-tissue defects as an alternative to surgical injectable grafting which uses your own tissue. Conventional injectable fat grafting requires a surgical liposuction procedure to obtain and process one’s own fat for injection. In a traditional fat grafting procedure fat is harvested from one part of he body and is injected into another part of yourface. With Allofill harvesting your own fat isn’t necessary since Allofill is ready to use off the shelf and can be applied like any other off-the-shelf injectable filler.

Allofill currently comes in 3cc syringes and is refrigerated until it is used. It has a two year shelf life.

Dr. Barry Eppley

Indianapolis, Indiana

October 25th, 2017

Case Study – Jawline Augmentation using a Three Implant Technique

 

Background: The shape of the lower face is primarily influenced by the size and dimensions of the mandible or lower jaw. Being the only moveable bone on the face it has a unique shape due to the biomechanical stresses placed on it as well as having to contain up to sixteen teeth that pass loading forces onto the upper jaw. It has three prominences that make up its identifiable tripartite structure, the anterior chin and the posterior jaw angles. While the chin is the mandible’s most recognized aesthetic feature, the jaw angles are really like the paired set of chins on the back part of the jaw.

While chin augmentation has been around for over five decades, jaw angle augmentation is much more recent. Unlike the chin, augmentation of the jaw angles can only be done by implants and doing so is far more complicated than that of the chin. Besides the anatomic fact there are two jaw angles, their location underneath the strong masseter muscles creates considerations of incision location, implant shape and size and its location on the bone and how it may affect muscular position and shape.

While the ideal method for total jawline augmentation is that of a custom made wrap around jawline implant, many patient’s may not need that technology or prefer not to undergo its use. Standard chin and jaw angle implants can work well for many patients and their wide variety of sizes and shapes create a lot of aesthetic jawline augmentation options. But how to mix and match these implant sizes and the challenges of placing three separate implants in their proper bony positions makes getting symmetric and aesthetically satisfying results challenging.

Case Study: This young male wanted a total jawline augmentation with a result that was of a modest enhancing effect. He didn’t want it too strong or to look overdone. His natural jaw was not weak or overtly deficient but had softer highlights of the chin and jaw angles.

Under general anesthesia, a small square chin implant was placed through a submental incision. Through posterior vestibular intraoral incisions, medium square widening jaw angle implants were placed and secured by titanium micro screws.

His after surgery results showed a more defined jawline that had better chin and jaw angle angularity. The implants had acceptable symmetry and were not oversized.

While this patient had a good result using standard chin and jaw angle implants, the risks of revisional surgery with three independent bone areas of augmentation is not low. Between the size and shape of the implants and their proper and symmetric placement on the bone, the average risk of an aesthetic revision for the dozens of influencing and interconnected possible variables is 50% or higher.

Highlights:

  1. Complete jawline augmentation consists of highlighting the three corners of the jaw, the chin and bilateral jaw angles.
  2. A wide variety of standard chin and jaw angle implants exist to satisfy many patient’s aesthetic jawline needs.
  3. With three independent implants along the jawline it is important that patient’s appreciate the relatively high rate of aesthetic revisions that can occur.

Dr. Barry Eppley

Indianapolis, Indiana

October 25th, 2017

Case Study – Submental Technique for Bony Chin and Jawline Asymmetry Correction

 

Background: Lower facial asymmetry is most commonly associated with the shape of the jawline. While patients often present with chin asymmetry, closer inspection often reveals that it extends back along the jawline as well. With the chin asymmetry the jawline on the longer chin side is lower and conversely it is higher on the shorter chin side. A debate can be had about which is the normal side and whether the condition is hypoplasia or hyperplasia which has great relevance when it comes to treatment planning.

True lower facial bony asymmetry has soft tissue asymmetries as well which would be consistent with that of a developmental origin. The lips will be tilted with different horizontal positions of the mouth corners. The base of the nostrils will be tilted and even the eyes may have subtle differences in the horizontal lines between the inner and outer canthi. Most of these soft tissue asymmetries are far less correctable than that of the underlying bone

Correction of chin and jawline asymmetry must take into consideration numerous anatomic factors. In the chin area the short length of the tooth roots do not pose any restrictions for the amount of bone that can be removed. But in the jawline behind the chin the location of the inferior nerve as it courses through the bone is, however, a potential surgical restriction. When vertical bone reduction is indicated (facial hyperplasia) preoperative x-rays are needed to determine the limits of these bony changes.

Case Study: This young female presented with chin asymmetry with a longer right side and a visible tilt of the chin to the left. Physical and radiographic examinations  showed that a right facial hyperplasia was the cause with vertical elongation of the entire jawline which drove the position of the chin to the opposite side. This was evident at facial rest but more apparent when smiling. A panorex x-rays showed the amount of bony differences between the two sides with the jaw angles and intrabony nerves highlighted.

Under general anesthesia a submental approach to the chin and right jawline resha[ing was used. Initially the chin asymmetry was addressed by an inferior border shave across the bone, horizontal deprojection and a left corner angled reduction. The right jawline ws reduced by an inferior border shave of 7mms back to the anterior attachment of the master muscle. Redundant soft tissue was removed over the chin area and the muscles reattached along the chin with sutures suspended to bone holes.

The immediate intraoperative view of the chin showed he improved symmetry as well as an overall rounding effect to ‘desquare’ the chin as well. The cant of the smile line and occlusion above the chin will remain the same as before surgery as would be expected.

The aesthetic management of the chin and jawline asymmetry from hyperplasia that does not include occlusal adjustments is based on removing bone along the inferior and/or inferolateral border. The submental approach offers a direct line of sight method doing so with the greatest accuracy and safety to the inferior alveolar nerve. The fine line scar under the chin is a reasonable aesthetic tradeoff for these more predictable any changes. Radiographic surgical planning is essential and, while 3D CT scans have the most visual appeal, a traditional panorex x-ray offers a vert measurable method to determine a safe amount of vertical bony reduction along the inferior borders.

Highlights:

  1. 1) Chin asymmetry is often associated with jaw asymmetry as well.
  2. 2) The submittal approach offers the most effective reshaping of the chin and jawline due to line of sight visual access.
  3. 3) The location of the metal nerve and tooth roots can limited the extent of bony symmetry that is possible to achieve.

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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