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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.

February 8th, 2017

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

 

Cheekbone reduction surgery typically is done by a double osteotomy technique. The anterior cut allows the posterior body of the zygoma (main body of the cheekbone) to move in. The posterior cut is done at the back end of the attached zygomatic arch just in front of the ear. These two cuts allow the whole side of the cheekbone to move inward. This creates the facial narrowing effect.

The anterior cheekbone osteotomy is done from inside the mouth and various design patterns have been described for it. But regardless of the design of the bone cut, it needs to be secured with a plate and screws to prevent inferior migration and sagging cheek soft tissues. Failure to do so is the most common cause of postoperative loss of cheek volume.

Posterior Zygomatic Arch Osteotomy Cut Dr Barry Eppley IndianapolisConversely, the posterior cut through the back end of the zygomatic arch is done externally through a skin incision. By making an incision at the back end of the sideburn hair, direct access can be done right down to the temporal process of the zygomatic arch.  An angled bone cut is then made just before the arch joins the temporal bone. This bone cut, combined with the anterior bone cut, allows the whole cheekbone segment to move inward. With plate and screw fuxation of the anterior, such rigid fixation may not be needed on the posterior cut to hold it in. The angled cut allows the tail of the arch to move inward and being self-locking.

Dr. Barry Eppley

Indianapolis, Indiana

February 8th, 2017

Case Study – Custom Chin Implant

 

Background: Chin augmentation has been around for a very long time and many implant materials and sizes have been used to do it. From this experience has come standard implant sizes that work for the vast majority of people seeking chin enhancement surgery.

But some patients seek changes that exceed what these standard size can create or have discovered through prior surgery that their expectations have not been met. In these cases only a custom designed implant may suffice.

Custom Square Chin Implant Design Dr Barry Eppley IndianapolisCase Study: This 35 year-old male had a prior history of multiple chin procedures including a square chin implant and a sliding genioplasty. While all of these procedure produced a better chin, they fell short of his ideal chin shape and size goal. Therefore a custom chin implant was designed that brought the chin forward 25mm and gave it a very square shape without having any lateral wings.

Custom Square Chin Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia and through a existing submental incision the custom chin implant was placed over the end of the chin bone after removal of the indwelling implant. It was secured with a single 2.0mm titanium screw.

Custom Square Chin Implant front view Dr Barry Eppley IndianapolisCustom Square Chin Implant result oblique view Dr Barry Eppley IndianapolisAt six months after surgery his chin shape was more square with some increased projection. He was pleased and had finally reached his aesthetic chin shape goal.

While custom chin implants can be made to any size and shape, it is important to consider how the soft tissue chin pad will drape over it. (or whether it will) While not all custom chin implants are of large dimensions, many are. The chin soft tissues will not adapt well with large amounts of spontaneous horizontal projection. This often causes tight tissues, lower lip stiffness and an abnormal appearance. It helps to have the chin soft tissues stretched out from prior chin augmentation procedures which is often the case before many patients seek a custom chin implant solution.

Highlights:

1) A custom chin implant is needed when the dimensions of standard chin implants can not create the desired effect.

2) An implant that provides significant horizontal projection with limited width requires a  custom design.

3) Very large chin implants require previous soft tissue expansion from prior chin augmentation procedures.

Dr. Barry Eppley

Indianapolis, Indiana

February 8th, 2017

Revisional Buttock Implant Surgery

 

Like implants placed anywhere on the body, buttock implants can also have complications. When one compares the two methods of buttock augmentation, fat injection vs implants, it is no surprise that the placement of an implant is associated with a higher rate of potential complications. But for those women and men who have inadequate fat harvest sites, buttocks implants are their only buttock augmentation option.

As overall buttock augmentation surgery has become more prevalent, the number of buttock implants being placed has also increased. As a result the number of implant complications has expectantly risen as well. Buttock implant complications include medical problems of wound dehiscence, infection, hematomas an seromas as well as aesthetic concerns of  size and shape. How well patients do with buttock implant revisions and their outcomes has not been previously studied or published.

In the February 2017 issue of the journal Plastic and Reconstructive Surgery, the first paper on this topic was published entitled ‘Revision Buttock Augmentation: Indications, Procedures, and Recommendations’.  In this paper the author reviews his twelve year experience in 43 patients who had revisional buttock implant replacement. The indications for buttock implant replacment were prior loss of implant (42%), asymmetry (37%) and size change. (21%) Revision buttock implantation procedures done were implant removal (24), implant replacement (19), implant exchange (18), capsulotomy (6), size change (5) and capsulorraphy. (1) Complications after the 24 buttock implant removals included contour irregularities that required fat grafting (2) but no infections o wound dehiscences were seen. Of great interest is what happened in the 19 buttock implant replacement patients. Infections occurred in 25% of them. Complications after buttock implant exchange was hematoma. (5%)

In primary buttock implant surgery the most dreaded complication is that of infection. Once it is diagnosed the recommendation is to remove the implant immediately and wait at least 6 months until it is replaced. Trying to replace the implant too early (just months after its removal) is associated with a higher rate of recurrent infection.

Implant asymmetry was seen equally in both subfascial and intramuscular locations. Its resolution requires either capsulotomies to expand the space or implant shape change.

Aesthetic buttock implant exchange for size and shape requires a good understanding of postoperative expectations. Oval shaped implants are good when the buttocks is long and lacks lower pole fullness. Oval implant rotation is treated by a round implant replacement. The typical implant size increase was 100cc with an additional cm in implant width.

The need for revisional buttock implant surgery is always a potential sequelae of primary implant augmentation and includes management strategies for the timing of primary implant removal and secondary implant replacement due to infection and seromas. Aesthetic implant revision must be tempered with balancing the potential risks vs how much buttock size and shape change will result.

Dr. Barry Eppley

Indianapolis, Indiana

February 7th, 2017

OR Snapshots – 3D Forehead Reconstruction Implant

 

Forehead reconstruction encompasses a variety of inlay and onlay bone procedures. Reconstruction of full-thickness frontal bone defects most commonly occurs from either neurosurgical procedures where a craniotomy bone flap has been lost or from skull bone loss due to trauma. While replacing the lost bone can be done by using the patient’s own bone, this is very much like ‘robbing Peter to pay Paul’. A large segment of full-thickness skull bone must be taken from another location on the skull, split into two halfs and then both skull defect sites have to be reconstructed with the bone segments.

As a result, the most common method for full-thickness skull bone loss is a synthetic material. There are a variety of implant materials available for use, but the use of 3D imaging and computer design dominates how such forehead bone reconstructions are done today. The precision fit of a 3D implant design made of a strong implant material is appealing for both surgeon and patient alike.

Custom Forehead Skull Implant Reconstruction Dr Barry Eppley Indianapolis3D forehead reconstructive implants can be made of metallic titanium, HTR polymer, PEEK and PEKK materials. Using a 3D CT scan the implant is prefabricated and usually fits with little modification needed. (often no adjustments of the perimeter of the implant are needed) This is an example of a 3D  forehead reconstruction implant made from PEKK material to replace a lost frontal bone flap due to infection from a prior intracranial tumor resection procedure.

PEKK is a synthetic polymer composed of polyetherketone ketone material. It is firm implant material that has a a high resistance to fracture. In addition it has a lighter weight than other materials like titanium. Its lightweight, high impact resistance and being able to be laser sintered in fabrication make its an excellent 3D cranial implant.

Dr. Barry Eppley

Indianapolis, Indiana

February 7th, 2017

Case Study – Weight Loss Tummy Tuck

 

Background: Weight loss creates a lot of external body changes that is usually most manifest in the trunk region. In the anterior abdominal region the deflated skin hangs often hangs over the waistline tethered by the belly button attachment. How mucb skin overhangs the waistline depends on how much weight loss one undergoes and what one looked like before the weight loss.

The tummy tuck is the standard treatment in the weight loss abdomen. Depending upon how much skin needs to removed the length of the horizontal can range from hip to hip or can extend completely around the waistline in a circumferential manner. When the extent of the tummy tuck matches the magnitude of the loose skin present, the abdominal contour change can be dramatic.

Case Study: This 23 year-old Hispanic female lost 60 lbs through diet and exercise over a one year period. (185lbs down to 125lbs) This left her with a central mound  of loose skin that was mainly restricted to the anterior abdomen.

MO Tummy Tuck result front viewUnder general anesthesia, a full tummy tuck as performed through a wide horizontal excision of skin with umbilical transposition. It was not necessary to extend the tummy tuck incision further back into the flanks areas.

MO Tummy Tuck result oblique viewMO Tummy Tuck result side viewAt one year after her surgery, her abdomen was reasonably flat. Her tummy tuck scar healed beautifully, being barely detectable even in her darker skin. She still had a fair amount of stretch marks but these were expected since they were outside the zone of the skin excision pattern.

Many weight loss tummy tucks produce good scars. The the skin closure, even though it is under tension,  heals favorably because of the loss of skin elasticity from the weight gain/loss on the dermal architecture of the skin.

Highlights:

1) Large amounts of weight loss causes unsightly loose skin on the abdomen.

2) A full tummy tuck removes much of the loose abdominal skin but can not remove all the stretch marks.

3) The stretched out abdominal skin heals well and creates a good tummy tuck scar.

Dr. Barry Eppley

Indianapolis, Indiana

February 6th, 2017

Case Study – Custom Male Forehead Implant

 

Background: The shape of the forehead is well known to be gender specific. Besides the prominent brow bones, the male forehead has a slight backward slope to it and is broader than that of a females. This slight backward slope contributes to the prominence of the brow bones with increasing slopes making the brow bones look bigger. (pseudo brow bone projection)

While there can be an acceptable retroinclination to the male forehead there comes a point when it slopes back too far and becomes aesthetically undesireable. What the exact angle is as to how much backward slope is aesthetically excessive defies a specific number but it is in the range of greater than 15 to 20 degrees.

3D Forehead Deficiency Dr Barry Eppley IndianapolisCase Study: This 45 year-old male was bothered by the backward slope to his forehead. While much of his forehead was covered by hair, he knew that beneath the hair the forehead sloped backward with two specific grooves heading back into the hairline along the temporal lines. A 3D CT scan of his forehead revealed its slope and lateral deficiency.

Custom Forehead Implant design Dr Barry Eppley IndianapolisCustom Foreheasd Implant design 2 Dr Barry Eppley IndianapolisA custom forehead implant was designed to decrease his forehead slope and make the whole forehead wider. At its thickest point the central thickness of the design was 5mm while the lateral thickness was 7mm before it tapered into the temporal muscle.

Custom Forehead Implant placement Dr Barry Eppley IndianapolisUnder general anesthesia, a 9cm long scalp incision behind his hairline was made. Subperiosteal dissection was done down to the brow bones and out onto the temporalis muscle fascia to accommodate the width of the implant. Multiple perfusion holes were placed into the implant prior to its insertion. After central positioning and making sure the edges were unfolded and laying properly, the scalp incision was closed in multiple layers with resorbable sutures.

A custom male forehead implant is the best way to create an overall contour change of the upper third of the face. It ensures the smoothest result from side to side as well as the smoothest transition possible into the temporal regions. Equally importantly it also allows for the smallest insertion scalp incision possible which is of critical importance in a male.

Highlights:

1) The male forehead has less of an inclination and is wider than that of a females.

2) A custom forehead implant in a male offers the smallest incision for its placement.

3) Thicknesses of only a few millimeters that cover a broad surface area like the forehead can make a visible difference.

Dr. Barry Eppley

Indianapolis, Indiana

February 6th, 2017

ePTFE-Coated Silicone Nasal Implants

 

ePTFE (expanded polytetrafluoroethylene) offers a facial implant material that is very biocompatible and also induces some tissue adherence. Due to the microfibrillar nature of its surface, ePTFE has some surface porosity where fibroblasts can attach and induce collagen attachments. ePTFE, however, does not come in any solid preformed facial implants and they have to be hand carved during surgery out of a block of the material.

For nasal implants, ePTFE offers a fairly easily and quick carving to get the desired length and shape. But it would still be preferable if a performed version of an ePTFE nasal implant existed.

ePTFE Composite Nasal Implant Dr Barry Eppley IndianapolisIn the February 2016 issue of the Annals of Plastic Surgery, a paper was printed on this very topic entitled ‘Silicone-Polytetrafluoroethylene Composite Implants for Asian Rhinoplasty’. Over a four year period, 177 Asian patients underwent rhinoplasty using a dorsal composite nasal implant.  (about 2/3s primary rhinoplasty and 1/3 secondary rhinoplasty) The average dimenions of the ePTFE coated silicone nasal implants was 1.5 to 5 mm thick and 3.8 to 4.5 cm long. Autologous cartilage was used for tip coverage in every case. Glabellar augmentation was also performed in 11% of the  patients.

There was an 11% complication rate which included implant malposition/deviation (5%), persistent redness (2%) and actual infection. (1%) There were no cases of extrusion. There was a 9% revision rate either due to malposition or inadequate dorsal height from the patient’s perspective. There were no complication differences between use of the implant in primary or secondary rhinoplasty.

The use of an implant, whether it is solid silicone or solid ePTFE, are mainstays of Asian rhinoplasty. They both havge their own distinct advantages and disadvantages…silicone offers a performed shape while ePTFE offers some tissue adherence. Silicone-polytetrafluoroethylene (PTFE) composites have a silicone core and a thin ePTFE coating. They appear to offer the advantages of silicone and ePTFE in a single implant. Despite that they have been around now for several years, there have been no published reports in them.d alternatives for rhinoplasty because of a lack of relevant reports. This clinical study shows that the short-term ouotcome is similar to that of ePTFE alone and can be effectively used for both primary and secondary augmentation rhinoplasty in Asians.

One of the keys to the use of any nasal implant is to keep it from putting too much pressure on the nasal tip skin. Thus the use of a cartilage graft over the tip area.

Dr. Barry Eppley

Indianapolis, Indiana

February 6th, 2017

Case Study – Dermal-Fat Graft Chin Reconstruction

 

Background: Soft tissue deformities of the chin are not uncommon and are created by a variety of etiologies. Trauma is the most common cause but developmental chin deformities also occur from hemifacial microsoma and autoimmune diseases from linear scleroderma for example.

Treatment of any soft tissue defects of the face are done by fat injections today. Their ability to introduce a natural soft tissue graft and to do so in a non-incisional method has a lot of appeal. The downside of injectable fat grafting is the unpredictability of its survival or persistence. But the potential need for multiple injection sessions is still worth the lack of creating incisional scars in most cases.

The dermal-fat graft is the original fat grafting procedure that dates back to World War I.  Technically the original technique was an enbloc fat graft. (without the dermis) A dermal-fat graft works because the blood vessels are hooked back up quickly within days to a week after implantation. It also helps that fat cells have minimal working parts to them. (just a nucleus) But their success is restricted to smaller graft sizes. Their disadvantages are that they require a donor site harvest and an incision for their placement.

Soft Tissue Deformity of ChinCase Study: This 45 year-old female suffered a traumatic injury to her chin which resulted in soft tissue atrophy due to the resultant hematoma. The left side of her chin was thinner and had soft tissue contraction and an obvious external deformity. She has some numbness of the mental nerve distribution on that side but a normal working marginal mandibular branch of the facial nerve.

to chin intraopUnder general anesthesia, a 4 x 6 cm dermal fat graft was harvested from the lower abdomen. Through an intraoral approach, a vestibular incision made dissecting out branches of the mental nerve. The chin soft tissues were released and a pocket made. The dermal-fat graft was inserted into the pocket and trimmed. A mucosal closure was done over the graft.

Dermal Fat Graft Chin Reconstruction result front view Dr Barry Eppley IndianapolisDermal-Fat Graft Chin reconstruction result oblique view Dr Barry Eppley IndianapolisHer three month after surgery result showed a near normal chin contour that was fairly soft and supple. No further surgery was required.

The dermal-fat graft is often overlooked in today’s plastic surgery where the injectable fat graft dominates soft tissue reconstruction. While the dermal-fat graft has its limitations, in the properly selected patient it can offer a one-time soft tissue grafting method of reconstruction.

Highlights:

1) Soft tissue deformities of the chin are best treated by fat injections.

2) Fat injections do not always survive and multiple injection sessions may be needed.

3) A dermal-fat graft provides a large soft tissue grafts that can be placed through an intraoral approach with good survival.

Dr. Barry Eppley

Indianapolis, Indiana

February 5th, 2017

Case Study – Forehead Reconstruction with Hydroxyapatite Cement

 

Background: Many well known congenital skull deformities (craniosynostoses) are treated by early surgery, usually under one year of age. While this allows the developing brain more space to grow and have it help shape the overlying skull, the final shape of the skull is rarely ideally normal. Scar, growth potential and genetics all play a role in preventing a consistent and reliably formed convex skull shape.

Such secondary skull deformities are most manifest in the forehead. Between its visible large contribution to the face and the frequent bone irregularities and temporal hollowing that develops from prior surgeries, the forehead can lack a smooth and pleasing shape. Forehead recession and narrowing along with temporal depressions makes for a commonly seen disproportionate forehead contour. Many of these patients will also have small metal plates and screws across the forehead and brow bones as well as some full-thickness bone defects.

Case Study: This 22 year-old female was originally born with a bilateral coronal craniosynostosis. She has previously undergone both early and several subsequent fronto-orbital reconstructive procedures. Her forehead had a recessed and inverted shape and the temporal areas at the side of the forehead had marked hollowing. There were also several areas of tenderness over the forehead underneath which were palpable metal hardware.

Hydroxyapatite Cement Forehead Augmentation Dr. Barry Eppley IndianapolisUnder general anesthesia and using the full extent of her existing coronal scalp incision, the forehead and temples were fully exposed. Over a dozen plates and thirty small screws were removed. Numerous full thickness bone defects were encountered with intact dura. Using over 150 grams of hydroxyapatite cement,  the forehead, brows and temporal region were built up to more normal contour. All full thickness skull defects were also covered at the same time.

NN Forehead Augmentation with Hydroxyapatite Cement result oblique view Dr Barry Eppley IndianapolisNN Forehead Augmentation withj Hydroxyapatite Cement result front view Dr Barry Eppley IndianapolisHer forehead and temporal areas showed much improved contours once all the swelling had resolved. This fronto-temporal augmentation improved what looked like a constriction band around the forehead just above the brow bones.

The use of hydroxyapatite cement is largely restricted to such procedures as forehead reconstruction due to its high cost. ($100/gram) Its working properties also make it most easily and consistently used with wide open exposure of the bone site. These two reasons keep hydroxyapatite cement from more frequent use in aesthetic skull reshaping surgery.

Highlights:

1) Forehead reconstruction of large contour defects from congenital skull deformities is best treated by hydroxyapatite cement.

2) Hydroxyapatite cement offers a smooth and highly biocompatible contouring material for long-term persistence.

3) The high cost of hydroxyapatite cements makes their use more common in reconstructive forehead reconstruction and not aesthetic forehead augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

February 5th, 2017

Case Study – Inner Ankle Liposuction

 

Background: The distribution of fat throughout the body is highly variable and is affected by numerous factors including gender, body habitus, weight, lifestyle and genetics. While excess fat (lipodystrophy) is commonly associated with a variety of central trunk areas, it can occur in the extremities as well. When occurring in the extremities without truncal adiposity, it occurs not because of diet but because of congenital lipodystophy. (just the way one was born and developed)

When excess fat occurs in the lower extremities at the ankles, it is commonly called ‘cankles’. This unflattering description signifies that there is little to no difference in diameter between the calfs and the ankles. While this is often associated with patients that are overweight, smaller amounts of ankle lipodystropy can occur in patients of normal weight.

Case Study: This 42 year-old male has long been bothered by the lack of shape of his ankles. He was of normal weight but has excess fullness on the inner side of his ankled between he ankle bone and the lower end of the calf muscle on each side.

Inner Ankle Liposuction Dr Barry Eppley IndianapolisInner Ankle Liposuction result Dr Barry Eppley IndianapolisUnder general anesthesia and in the supine position, local anesthesia with epinephrine was first injected into the marked inner ankle areas. Using a small 3mm cannula the inner ankles were aspirated of 65cc of fat per side with a total of 130cc removed. (this picture shows the difference between one inner ankle treated and the other not yet treated) For the ankle area in an otherwise thin person this is a lot of fat for such a small extremity area. Compression wraps were placed for dressing.

Inner Ankle Liposuction result front view Dr Barry Eppley IndianapolisIn the properly selected patient I have always been impressed with with ankle liposuction can accomplish. The area has to be treated aggressively with the intent of leaving little fat between the skin and the underlying muscle fascia and achilles tendon. Because it is doing liposuction around a functionally loaded and moving joint, the patient should expect that there will be some prolonged swelling and walking discomfort. Because the ankles are in the most dependent position on the body, they will take months for all the swelling to completely resolve and see the final result.

Highlights:

1) Excess fat collections due to congenital fat distribution can affect non-overweight patients.

2) Small cannula liposuction can be very effective at removing fat from the inner and outer ankles.

3) While it is a small area of liposuction it takes the ankle area longer to recover than one would think.

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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