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.

July 1st, 2017

Technical Strategies – Shortening Vestibuloplasty

 

Soft tissue malposition of the anterior lower face is manifest in several presentations. Chin ptosis or sagging refers to the hanging of the soft tissue chin pad off the end of the bone. It most commonly occurs from some type of chin surgery that has stretched out the soft tissue attachments. Chin implant removal is a classic example of its cause although not the only one. It can also occur from a sliding genioplasty setback, multiple intraoral chin surgeries and aging associated with alveolar bone loss.

Chin ptosis may also be associated with lower lip incompetence. As the chin pad tissue slides off of the bone it may pull down on the lower lip, creating lack of lip closure at rest and lower teeth show. This creates a dual negative perioral effect.

The most well known treatment for chin ptosis and/or lower lip incompetence is mentalis muscle resuspension. This well chronicled procedure reattaches the bony origin of the muscle higher up on the bone often at a position between the incisor tooth roots. The muscle drags up with it the overlying soft tissues of the chin pad correcting chin pad ptosis and pushing up the lower lip. While these effects of muscle manipulation often look good during surgery, they unfortunately are often not maintained as well as one would like particularly that of the lower lip.

As a result other adjunctive procedures are commonly done with mentalis muscle resuspension to help improve its long-term success rate. One of these procedures is a vestibuloplasty, specifically a shortening vestibuloplasty. The anterior mandibular vestibule is the lined space between the teeth and the lower lip. The depth of the vestibule is usually a reflection of the superior position of the mentalis muscle on the bone. With a deep vestibule the superior muscle attachment is located lower and often so is that of the lower lip.

In a shortening vestibuloplasty the mucosal lining of the depth of the vestibule is removed and a layered closure is done. This raises the height of the vestibule (shortens its depth) and helps provides support to the elevated lip.

Dr. Barry Eppley

Indianapolis, Indiana

June 27th, 2017

Clinic Snapshots – Retrotragal Facelift Incision

 

The facelift is one of the most common of all facial rejuvenation procedures. While there area a myriad of methods to perform it with various technical maneuvers that can seem bewildering to the patient, the most basic part of it remains the incision around the ears. While perhaps not the most technically challenging part of the operation it is certainly the most visible.

No matter how well the ‘inside’ of the facelift procedure is performed, poor incision placement, adverse scarring and hairline displacements/distortions will be an aesthetic detraction. These external markers can often be how a facelift is judged and is an understandable preoperative patient concern.

The basic facelift incision around the ear is often called preauricular or retrotragal. This refers to the incision on the front of the ear which represents a part of the total facelift and just a minor portion of its total incisional length in most cases. But it is the most visible part of the incision and thus its aesthetic importance.

In almost all women and in many men the facelift incision will be placed in a retrotragal fashion. The incision will go inside or behind the cartilage bump (tragus) as it crosses this part of the ear. Otherwise the rest of the incision runs in the natural face-ear junction around the ear and up and back into the hairlines. Such placement hides part of the incision and helps break up scar tension on it due to its non-linear course. (this is an example of such an incision several weeks after surgery.

These type of facelift incision usually heals quite well and as discretely as one would hope. This is because it is not only hidden but because it is closed with no tension after the excess skin is removed.

Dr. Barry Eppley

Indianapolis, Indiana

June 26th, 2017

OR Snapshots – Rib Removal Cartilaginous Ends

 

Rib removal is the last surgical option for maximal waistline reduction. After liposuction the only remaining anatomic obstruction is the lower ribcage. The outer and downward flare of the free floating ribs does influence the width of the waistline at the horizontal level of the umbilicus. Contrary to its perception rib removal is not a myth or an urban legend but an actual procedure that is both safe and effective. The aesthetic tradeoff is the small fine line scar on the back which is needed to do the procedure.

Rib removal is really subtotal rib removal, only the outer portion of the rib is removed. There is no aesthetic benefit to removing the whole rib by disarticulating it from its vertebral facets. The rib only needs to be removed back to the outer edge of the erector spinae muscle. At this point a full-thickness bony cut is done to separate from its medial attachment.

The rib is then dissected out laterally in a circumferential suboperiosteal fashion until its cartilaginous tip is reached. At the cartilaginous end numerous muscular and fascial attachments exist. These are easily stripped off. Thus aesthetic rib removal involves only one bone cut per rib as the distal end is ‘free’. (not attached to bone but its does have soft tissue attachments.

In some cases of rib removal for maximum effectiveness, rib #10 is also removed in a subtotal manner also. Even though it is not a true free floating rib it still has a cartilaginous attachment to the anterior subcostal ribcage at the 7-8-9-10 cartilaginous unit.

Dr. Barry Eppley

Indianapolis, Indiana

June 25th, 2017

Custom Cheek-Maxillary-Paranasal Implant

 

Cheek implants provide augmentation to the cheekbone or zygomatic major bony prominence. This produces an anterolateral midface effect that is useful for more common augmentations of isolated and mild to moderate aesthetic cheek deficiencies.

But the cheekbone is part of the overall midface skeleton with extensions onto the eye (infraorbital rim) and the upper jaw. (maxilla) As a result, when midface developmental deficiencies occur or in certain ethnicities the facial effects are more than just a lack of adequate cheek projection. The entire midface can be deficient as manifest with a flatter face appearance that lacks overall horizontal projection.

In midface deficiences standard cheek implants do not address the complete skeletal problem. Making custom implants to have broader coverage of the midface provides a more complete solution. Extending the implant down onto the face of the maxilla and over to the pyriform aperture provides a zygomatic-maxillary augmentation effect. Short of the central upper lip and teeth changes, this design creates a LeFort I advancement effect with cheek augmentation.

This custom cheek-maxillary-paranasal implant is placed through an incision inside the mouth like standard cheek implants are. It is easier to position than standard cheek implants due to its length and visible positioning up against the pyriform aperture. The risk of malposition is low as most of the implant is visible inside the mouth during placement.

Dr. Barry Eppley

Indianapolis, Indiana

June 23rd, 2017

Case Study – Cupid’s Bow Upper Lip Reduction

 

Background: Unlike the lower lip, the upper lip has a prominent shape feature known as the Cupid’s bow. This is a very recognizable lip feature which has a double curve in its central portion that derives its name because it resembles the bow of Cupid the Roman god of love. The height of the double curve aligns with the bottom end of the bilateral raised philtral columns which gives the lip ma bow appearance.

The degree of definition or prominence of the Cupid’s bow varies widely amongst individuals. To some degree the visibility of the Cupid’s bow is correlated to the natural size of the lip. (amount of vermilion fullness) The thinner the upper lip the flatter are the peaks of the bow and vice versa. Most  Cupid;’s bows have a rounded upper shape although some people have a sharper or more triangular bow form.

In the vast majority of women that seek upper lip augmentation, enhancement of the Cupid’s bow is desired. Having a fuller upper lip bow appearance is felt to be more attractive and sensual. Rarely is a request to have a flatter bow shape where the upper lip has a more homogenous shape like the lower lip.

Case Study: This 42 year-old female wanted to get rid of her upper lip Cupid’s bow. She wanted a smooth vermilion-cutaneous border from one mouth corner to the other.

Under local anesthesia the height of the Cupid’s bow was marked as two small wide-based triangles. The vermilion triangles were excised and the skin edges were advanced downward, making for a smooth vermilion-skin border.

Reduction of the Cupid’s bow is an uncommon upper lip reshaping request. But it can be done effectively through triangular vermilion excisions under local anesthesia.

Highlights:

  1. The shape of the cupid’s bow is the most noticeable and attractive feature of the upper lip.
  2. Reduction of the shape of the cupid’s bow is an uncommon upper lip reshaping request but can be done.
  3. Flattening of the prominence of the cupid’s bow can be done by vermilion peak excision.

Dr. Barry Eppley

Indianapolis, Indiana

June 23rd, 2017

Case Study – Breast Augmentation with Nipple Lift for Asymmetry Correction

 

Background: Many women that present for breast augmentation surgery do not have perfectly symmetric breasts. Women that have never had breast implant surgery rarely have symmetric breasts either. Yet, understandably, the woman who undergoes elective aesthetic breast surgery seeks the most symmetric result possible.

Of all the aesthetic breast deformities that exist, asymmetry is the most common and comes in many forms. The breast mound may be smaller on one side, there may be more sagging on one breast versus the other and/or the nipple may be lower. Since every women has some degree of asymmetry it behooves the surgeon and the patient to take careful note of it before surgery when a plan for intraoperative management can be done.

Differences in the horizontal level of the nipple is a very important asymmetry to note before surgery as breast augmentation will almost always make it worse. It is also often correctable by an adjustment done directly on the nipple. Known as a superior crescent mastopexy (SCM), ity is better referred to as a superior nipple lift. The superior half of the lower nipple can be lifted upward by about a centimeter or so through a crescent-shaped skin excision pattern.

Case Study: This 36 year-old female wanted a better breast shape. She was aware of her breast asymmetry with the right breast being bigger with greater skin sag and a resultant lower nipple position.

Under general anesthesia and through inframammary incisions, 400cc high profile breast implants were placed in a dual plane position. A right nipple lift was then performed through a half-moon shaped skin excision that was 1 cm at its central area.

Horizontal nipple asymmetry can and should be corrected at the time of breast augmentation with a nipple lift on the lower breast mound. Good implant sizing can overcome breast mound differences but will not on its own correct nipple level differences and may even make them worse. The superior areolar scar can heal quite well in most cases and does not create an aesthetic distraction.

Highlights:

  1. Breast asymmetry is the most common ‘deformity’ in prospective breast augmentation patients.
  2. Implants alone can not be counted on for correcting breast size or shape issues.
  3. A superior nipple lift on the more ‘saggy’ breast side during breast augmentation can help correct asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

June 22nd, 2017

The Model Cheek Implant (Malar-Arch Design) for the High Cheekbone Look

 

Cheek implants have been around for decades and have undergone an evolution of design changes. While initially developed as small oblong shapes to sit on top of the malar eminence, newer designs have incorporated the area under the malar eminence as well known as the submalar region. This has led to a variety of current shapes that include malar, submalar and combined malar-submalar (shell) styles, creating up to five different cheek implant options. (not to mention the various sizes of each style)

But careful analysis of the actual anatomy of the zygomatic complex (aka cheekbone) reveals that it does not match the shape of any current cheek implant. Structurally the cheekbone is fairly complex with a main body and three processes that articulate with other bones (frontal, temporal and maxillary) and has four borders. When the term ‘high cheekbones’ is used from an attractive and desirous facial beauty standpoint, this usually refers to more pronounced zygomatic arches or its posterior process. This causes a raised line along the sides of the face to appear which creates a distinct facial skeletal feature. This is often seen in fashion models in both men and women.

No performed cheek implant today truly creates the ‘model cheek’ look as they do not incorporate the zygomatic arch process as part of their design. To achieve this effect a special designed cheek implant is needed.  It can have various anterior shapes but the key element in the extended posterior zygomatic arch process. This extension can go back all the way to the temporal region if desired. Besides creating the raised line back from the cheek it also creates a smoother and more blended flow up across the cheeks  and back along the face rather than just a raised ‘bump’ over the cheekbone.

This malar-arch cheek implant design is placed in the standard intraoral fashion through the mouth. Subperiosteal dissection is carried way back along the zygomatic arch. As long as one is right on the bone there is no danger of injury to the frontal branch of the facial nerve that crosses in the tissues above the posterior zygomatic arch. The length of the tail of the implant can be shortened based on the patient’s anatomy and aesthetic goals. Because the implant has a long surface area contact with the bone in a more horizontal orientation the risks of intraoperative implant malposition and postoperative migration (if screw fixation is not used) is greatly reduced.

The model cheek implant is a malar-arch design that adds a skeletal coverage area not previously seen in any previous midface implant. It creates the high cheekbone look that many younger patients today seek in with contemporary fashion and beauty trends.

Dr. Barry Eppley

Indianapolis, Indiana

June 22nd, 2017

OR Snapshots – Rib Graft Tip Rhinoplasty

 

While many rhinoplasties are reductive in their overall reshaping effect, some require the addition of support or structure through the use of autologous tissue grafts. Most noses can be satisfactorily augmented or rebuilt through the use of septal, ear or combining septal and ear cartilage grafts. But when such local and regional cartilages harvest sites are depleted or inadequate for the amount of augmentation needed, the rib is the remaining ‘go to’ cartilage donor site.

Rib grafts offer an unlimited supply of cartilage graft material when it comes to what is needed in the nose. Regardless of where it is harvested (inframammary or subcostal incisions), the amount of donor material is more than adequate. Issues such as curved cartilage shapes (ribs are rarely perfectly straight) and whether full-thickness or in situ harvesting methods are used may pose some graft limitations But these are overcome by experienced harvesting techniques.

In the tip of the nose, rib grafts are needed when considerable tip lengthening or derotation changes are needed.  (rib graft tip rhinoplasty) Placing an L-shaped cartilage construct at the end of the nose has a powerful tip augmentation effect which is only limited by the ability of the skin to stretch over it and still have adequate perfusion after surgery.

Rib grafting to the nasal tip is often an onlay technique where the grafts are placed over the existing medial footplates and dome cartilages. A pocket is made under the columellar skin below the incision down to the anterior nasal spine into which one carved piece of the tip graft is placed. (vertical graft component) A lower dorsal-dome cartilage graft (horizontal component) is fashioned and placed on top of the existing dome cartilages to be united at 90 degrees to the columellar piece. Suturing the two rib grafts together creates the new tip defining point.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Custom Occipital Skull Implant Markers

 

Background: A flat back of head is one of the most common aesthetic skull problems that is treated. It is best augmented with a custom skull implant made from the patient’s 3D CT scan. This lessens dramatically the aesthetic risks of implant irregularities and edge transitions as well as asymmetry of the contours of the augmentation. There is a huge advantage to controlling the shape and thickness of the implant before surgery. This then leaves the role of the surgeon during surgery to ‘merely’ position it on the skull as it was designed.

The other major benefit to a custom implant that is flexible is that it can be inserted through a smaller scalp incision than that of the diameter of the implant. Every cm of scalp incision (or less thereof) can be of valuable aesthetic consequence. This also speaks to the value of a preformed implant whose shape and thickness can not be altered by the insertion process.

While a smaller scalp incision is of aesthetic benefit, it also severely limits a view of the implant’s position on the skull bone. Not seeing the circumference of the implant’s position on the skull bone can potentially create implant malposition. A curved implant on a curved bone surface under the compression of the overlying scalp can make it seem that just about any implant position is correct.

Case Study: This 57 year-old female had long been bothered by the flatness of the back of her head. (crown area or upper occipital region) Using a 3D CT scan, a custom occipital skull implant was designed to maximally augment the deficient skull area within the constraints of what the scalp stretch would allow.

Under general anesthesia and in the prone position, a 9cm long irregular scalp incision was made over the nuchal ridge. From this incision wide subperiosteal undermining was done with instruments up over the crown way into the top of the skull towards the forehead. The custom skull implants was inserted by folding the sides under creating a more narrow rolled tube. Once inserted the folded sides were unrolled and the implant flattened into the shape by which it was designed. It was then properly positioned by using the compass marker manufactured into the back edge of the implant to get both the midline positioning as well as having no right or left tilt. It was then secured with two small microscrews and the incision closed.

Most custom skull implants benefit in positioning with an embossed compass marker, regardless of what skull area they cover. The limited view of the implant with discrete scalp incisions requires visible registrations to aid in its orientation.

Highlights:

  1. A custom occipital skull implant is the most effective way to build up a flat back of the head.
  2. Proper  positioning of a skull implant in which the scalp incision. permits limited visibility requires a registration mark on the exposed part of the implant.
  3. A compass marker provides a 3D orientation method for skull implant positioning.

Dr. Barry Eppley

Indianapolis, Indiana

June 19th, 2017

Case Study – Older Maximum Breast Reduction

 

Background: Reduction of large breasts is one of the most common body contouring procedures in plastic surgery. It has been around in various forms for almost one hundred years. It is a uniformly successful procedure for reducing the back, neck and shoulder pain that typically accompanies large sagging breasts as well as positioning the breasts back up on the chest wall.

By the way it is designed every breast reduction procedure is also a breast lift. While a breast lift can be done without a breast reduction, the reverse is not true. A reduced amount of breast tissue means that the skin that contains it also must be less. The markings made on the skin before surgery is the breast lift part and is a very mathematical and precise part of the procedure. The reduction of the breast tissue is internal and is much more of an artistic technique rather than one that lies on measurements of angles and linear distances.

Breast reduction in older mature women. often has a slightly different flair to it. Women that have had large breasts all their life, and who have finally come to the point of wanting them smaller, usually want a more aggressive reduction. The need for symptomatic paint relief and the desire to look less matronly mandate that larger amounts of breast tissue be removed.

Case Study: This 65 year-old female had large breasts her whole life. (DD + cup size) She had three children and her breasts always ended up looking about the same afterwards albeit a bit more droopy. She was ‘over’ having large breasts and wanted the freedom in its clothing and exercise to have more freedom of choice.

Under general anesthesia an inferior pedicle breast reduction was performed with the removal of approximately 800 grams per side. Her nipple-arolear complex was raised 9 cms from a 30 cm length from the sternal notch to the nipple to a 21 cm length.

Older women are almost always more concerned about having a ‘maximal’ reduction procedure on their breasts than they are about having a fuller lifted shape. As  long as they sit much higher up on they chest wall with a more centered nipple with a low volume, they will enjoy the benefits of less to no musculoskeletal discomfort and the freedom should they so choose to even go without a bra.

Highlights:

  1. Breast reduction in older women is often a ‘maximum’ reduction and lift procedure.
  2. Getting reduced breast tissue back up on the chest wall is ultimately what causes a reduction in musculoskeletal symptoms.
  3. The inferior pedicle breast reduction technique offer a reliable and safe method for larger breast size reductions.

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