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.

April 30th, 2017

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

 

Reduction of prominent cheekbones requires some form of bone reduction. While some may think that shaving or burring can reduce the width of the cheekbones, this is largely an ineffective technique. This is because the only portion of the cheekbone that is accessible for shaving is the most anterior portion right below the eye. This is the anterior or front edge of the zygomatic body which does not have much influence on cheekbone width.

Significant cheekbone reduction requires  moving the arch portion of the zygoma inward. It is the zygomatic arch, or the connection between the zygomatic body and the temple bone that creates cheek width. This is because it is a curved bone structure even though it is a very thin bone of just a few millimeters in thickness. Its natural convex shape creates the widest part of most people’s face.

As a result of its spanning structure, cheekbone reduction surgery requires cutting the front and back end of the arch and moving it inward. The front bony cut is done from inside the mouth and often includes a portion of the zygomatic body . The back or posterior zygomatic arch cut, however, does not include the temporal bone and is done through a small incision in front of the ear at the back of the sideburn (in men) or the preauricular tuft of hair. (in females)

This direct access allows the posterior zygomatic arch to be fully visualized, cut and repositioned with small plate and screws fixation. The location of the dissection is above the path of the frontal branch of the facial nerve so the risk of injury to it is very low.

The usual amount of inward movement of the posterior arch is 5mm to 6mms which usually matches the front end of the osteotomy cut and inward movement.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2017

Case Study – Macrotia Reduction Surgery

 

Background: The ear has a complex structure that is often unappreciated due to its relative obscurity on the side of the head. But when something about its structure makes it stand out, it becomes open to considerable aesthetic scrutiny. The most common aesthetic distractor is when the ear sticks out too far from the side of the head or when it has congenital deficiencies in its structure.

One very noticeable aesthetic deformity of the ear its when it is too large or vertically long. While there are numbers for normal ear sizes and relationships to other structures of the face (e.g., nose), what ultimately matters is whether the patient thinks that it is too large. Usually patients are quick to notice earlobes that are too long or hang too low.  But large conchal bowls or upper ears can also be points of aesthetic concern.

Ear reduction or macrotia surgery is much more rarely performed than of the protruding ear which can also be called large ear reduction. (even though the actual ear is not too large and no parts of the ear is being resected) Macrotia reduction surgery must remove actual portions of ear structure (skin and cartilage) to create a visible reduction in the size of the ear but also must do with the location of the scars in mind so as to not create an aesthetic distraction.

Case Study: This 35 year-old male had been bothered by the size of his ears since he was young. He had undergone a setback otoplasty and wedge earlobe reduction but this did not make his ears look any smaller.  He had a vertically long earlobe and a wide scapha between the helical rim and the superior crus in the upper third of his ear. His vertical ear length was 72mms

His macrotia reduction plan was to reduce the upper size of the ear through a scaphal flap with 5mm mid-helical rim reduction. The earlobe would be vertically reduced through an inferior rim resection technique of 7mms.

Under local anesthesia using a periauricular regional bloc technique, the scaphal flap and earlobe reductions were completed using all dissolvable sutures. His immediate post results show an ear reduction with the vertical length reduced to 64mms.

Macrotia reduction requires the removal of ear tissues and the creation of scars. With the scaphal flap and inferior rim earlobe reduction techniques, the only scar of any consequence is the one that crosses the helical rim in the middle of the ear. This small scar usually heals extremely well and has yet to be one that any patient had asked me to revise.

Highlights:

  1. Macrotia reduction often involves a ‘high and low’ approach to be most effective.
  2. Scaphal reduction of the upper ear and vertical reduction of the earlobe are the two principal elements of macrotia reduction.
  3. Reduction of the large ear can be done under local anesthesia using periauricular ring blocks.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2017

Upper Eyelid Corrugator Muscle Resection

 

The frowning expression creates the well known ‘11s’or vertical wrinkles of the forehead. This is caused by the corrugator muscles drawing the eyebrows down and inward. It is partially a protective function for the eye from the glare of the sun and bright lights but also commonly appears when one is concentrating as well as ‘suffering’. Botox is a most common and highly aesthetic effective treatment for glabellar frown lines. The injections are targeted towards the corrugator supercilii, procerus and depressor supercilii muscles.

The corrugator supercilii are small paired muscles with a pyramidal shape which are located along inner edge of the brow bones at the nose. They are located beneath the overlying orbicularis oculii and frontalis muscle but do send fibers that pass through them to attach to the underside of the skin. An understanding of this anatomy has lead to their surgical treatment through a direct or upper eyelid incision for their resection leading to elevation of the medial brow and reduction of glabellar frown lines. This direct muscle resection approach also come in useful in the surgical treatment of frontal migraines.

In the February 2017 issue of Aesthetic Plastic Surgery, a paper was published entitled ‘Transpalpebral Corrugator Resection: 25-Year Experience, Refinements and Additional Indications’. In this paper the senior author discusses his experience and expanded techniques from the transpalpebral corrugated muscle resection technique that he introduced in the early 1990s. He lists the modifications of his eyelid approach as follows: 1) a thin layer of depressor supercilii muscle is removed to expose the corrugator supercilii muscle, 2) a medial branch of the supraorbital nerve is used to trace a path through the muscle down to the periosteum, 3) a portion of the muscle lateral to the nerve is removed, 4) a superior segment of the muscle is removed by electrocautery, 5) a lateral  segment of the procerus muscle is also removed, 6) for migraine surgery the supratrochlear and supraorbital arteries are cauterized as well as a foraminotomy if the nerve is fully encased by bone, and 7) fat injections are done to restore lost volume from the tissue resections.

The small size of the corrugator supercilii muscle and the limited access of the upper eyelid incision mandate a precise surgical technique for its resection if it is to be effective. Such refinements in the technique has described by this paper have led to improved results and addtionalk indications for its use.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2017

Forehead Augmentation by Fat Injections

 

Forehead augmentation can be done using a variety of materials and methods. It is probably most popular worldwide in Asians who often have a flatter and less convex forehead shape. While the use of synthetic materials is the most effective and assured forehead augmentation method, m both in terms of shape and longevity, it is an invasive procedure that requires some form of a scalp incision to have the forehead implant material placed.

Given the success of injectable fat grafting for facial voluminization, whether it could work as well in the forehead remains an intriguing consideration as another option for forehead augmentation in select patients.

In the March 20178 issue of the International Journal of Plastic Aesthetic and Reconstructive Surgery a paper was published entitled ‘Micro-autologous Fat Transplantation (MAFT) for Forehead Volumizing and Contouring’. In this paper The authors report on 178 patients (167 female, 11 male) over a 5-year period with an average nearly three year followup. Using harvested fat that was prepared by centrifugation, the forehead was augmented by an injection gun device. The procedure took under one hour to complete and averaged around 10ccs of injected fat. Not complications occurred such as infection, irregularities  or nerve injuries occurred, The authors reported that over 80% of the patients were satisfied with their results.

The proper title for this paper should have been Small Volume Forehead Augmentation by Injected Fat. With an average injection volume of just 10ccs of fat placed the amount of forehead augmentation obtained was very modest and in the central forehead location. In my forehead augmentation experience such a small amount of forehead augmentation would satisfy few patients even with an uncomplicated outcome.

But for those patients that seek very modest forehead augmentative changes, fat injection is a good technique as it avoids any scar from incisional access and has no significant risks. Like all fat injections, the survival and persistence of the fat transplants are not assured. But low volume micro fat grafts in the facial area has a known high rate of retention and the forehead should be no exception..

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2017

Earwell Ear Molding System – Long term Clinical Results

 

Congenital ear deformities are not uncommon and are always obvious right after birth. While some would say that this is reflective of being compressed inside the womb and misshapen ears can be a self-solving issue, this is almost never the case. The concept of early ear manipulation to work with the cartilage molding capability that exists for a short time after birth is well known to offer a non-invasive and effective treatment approach. Such early efforts can help normalize the ear shape and avoid invasive and sometimes difficult surgery later.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery the paper entitled ‘Classification ion Newborn Ear Malformations and their Treatment with the Earwell Infant Ear Correction System’ was published. In this paper the authors review their experience with 175 infant patients with over 300 ear deformities using the Earwell ear reshaping device. The average age treatment was begun at 12 days after birth with an average treatment period of 37 days requiring six office visits. The most common ear deformity treated was that of the constricted ear for which they developed their own classification system based on various ear features. (I through III with increasing severity) The most important feature of this classification was that of the horizontal axis which also determines how successful infant ear molding can be due to the initial severity of the ear constriction.

Treatment outcomes were determined by comparing the percentage of the deformity completely corrected vs. percentage still with appreciable residual deformity. Complete correction was achieved as follows: lidding (92%), conchal crus (90%), helical rim (86%), stahl (85%), prominence (80%) and Darwin tubercle. (50%). Overall treatment outcomes were rated as excellent to good in 88%, fair in 11% and poor. (1%) Complications were superficial excoriations which occurred in about 8% of the ears treated.

While the Earwell molding system for congenital ear deformities has been around for awhile, this is the largest series reported of its long-term results. While it has been known for a long time that very early efforts at reshaping a deformed ear can be helpful, having a effective and consistent method to to do so has been lacking until the Earwell system became clinically available.

Several important points about the Earwell system is that its use must be initiated as soon as possible after birth. In this paper their average age of beginning treatment was less than two weeks after birth which is ideal. I get many a parent who calls a month or six weeks after birth to begin treatment. The success at this delayed time of treatment initiation drops precipitously as the cartilage pliability changes. The other very important point is that the Earwell device does more than just fold the ear cartilages back into a more favorable position. The genthe and sustained forces on the helical rim causes actual cartilage expansion and lengthening.  This explains its success in improvement of even the more significant constricted ear deformities who have a true lack of cartilage volume.

Dr. Barry Eppley

Indianapolis, Indiana

April 30th, 2017

Case Study – Extreme Upper and Lower Lip Advancements with Mouth Corner Lifts

 

Background: Lip augmentation is one of the most popular non-surgical facial enhancement procedures. Done primarily by synthetic injectable fillers the size of the lips can be increased for the duration of the filler’s persistence. When skillfully done injectable fillers can create a myriad of perioral effects from lip size increase, correction of lip asymmetries and corner of the mouth lifts.

The effectiveness of fillers in the lip is based on having enough vermilion height so it can be expanded superiorly as well as outward. When the lips are very thin with a small amount of vermilion show, the push of the fillers is going to more outward than upward. This creates the dreaded ‘ducklip’ effect in which the lips are disproportionately balanced between their projection and height.

With poor responses to fillers in thin lips, changing the location of the vermilion border is the most effective approach. This his known as a lip advancement procedure and can be done on both the upper and lower lips. It is particularly effective in vermilion height asymmetries due to the ability to precisely change the location of the vermilion-skin border line.

Case Study: This 35 year-old female wanted bigger lip but also correction of her natural upper lip asymmetry. She previously had a congenital nevus removed from the left side of her upper lip which further contributed to her natural lip asymmetry. She had injectable fillers placed into her lips numerous times in the past but didn’t want to continue with that recurring expense.

Under local anesthesia with infraorbital and mental nerve blocks, lip advancements were performed. A 3mm lower lip advancement and an asymmetric 5/3.5mm upper lip advancement were performed combined with corner of the mouth lifts through a triangular skin excision. At the end of the procedure, the instantaneous size increase and improved lip symmetry could be seen. Between the use of local anesthetic and swelling, the lips looked enormous in size at the completion of the procedure but this will recede to a more normal appearance in 10 to 14 days later.

Highlights:

  1. Lip advancements are the most powerful surgical form of lip augmentation as they affect the whole lip from corner to corner.
  2. Lip advancements are the most effective form of lip asymmetry correction whether it is a partial or complete advancement.
  1. Upper and lower lip advancements done together create the most dramatic effects even at 3mm to 4mms of advancement per lip.

Dr. Barry Eppley

Indianapolis, Indiana

April 29th, 2017

Case Study – Extreme Two-Stage Vertical Chin Lengthening

 

Background: The sliding genioplasty is a well known chin augmentation technique for horizontal advancement of a short chin. It is used most commonly for the horizontally deficient bony chin. With these forward movements some vertical change can also be affected, either opening it slightly or even vertically shortening it.

A lesser known use of the bony genioplasty is to vertically lengthen the chin. This its actually the simplest movement of the inferior chin segment as it is opened up and elongated using the posterior bony wings as a cantilever. The amount of elongation is based on the vertical width of the bony gap created between the upper and lower segments. The gap is stabilized by a spanning titanium plate with two screws above and below for form fixation. When the bony gap gets to 8mm to 10mms an interpositional bone graft is used to ensure bony healing.

How much one needs to aesthetically lengthen the chin can be determined by preoperatively opening the jaw, find the best chin lengthening effect and then measuring  the distance between the upper and lower teeth edges. (minus any upper incised overbite)  If the vertical distance exceeds 10mm to 12mms, one will ned to consider a two-stage vertical chin lengthening approach.

Case Study: This young male wanted to vertically lengthen his chin. It was determined that 10mm was a good and maximal distance. The horizontal osteotomy was made and the 10mm opening wedge gap stabilized with an 8mm chin step plate that was flattened out. A cadaveric block bone interpositional bone graft was placed in the gap.

Six months later a panorex x-ray shows complete bony consolidation across the graft site as well as at the end of the original osteotomy bone cuts. The bony spaces between the bone graft and the ends remained incompletely filled.

He wanted an additional 10mms of vertical chin lengthening  so a second bony genioplasty was performed. The metal plate and screws were easily removed (non-bony overgrowth) and the chin bone was solid. A horizontal bone cut was made across the original osteotomy line and the chin easily downfractured. It was dropped down another 10mms, fixed with a flattened out 12mm step chin plate and secured with screws. Another interpositional bone graft was placed on both sides of the bony gap.

Interestingly at 20mms of vertical chin lengthening, no lower lip incompetence of strains occurred. Presumably this was because it was a staged bony lengthening approach.

Highlights:

  1. Vertical lengthening genioplasty lengthens the lower third of the face by an opening wedge osteotomy.
  2. When the vertical lengthening of the chin is at 8 to 10mms a cadaveric interpositional bone graft is needed for bony healing
  3. A second vertical lengthening genioplasty can be successfully done after the first one with a final lower third of the face increase of 20mms.

Dr. Barry Eppley

Indianapolis, Indiana

April 29th, 2017

OR Snapshots – Chin-Jawline Implant

 

Chin augmentation has been done for a long time and many different implant materials and shapes have been used. The most common chin implant used today is that of an extended or anatomic design. Rather than just sitting on the front edge of the chin this contemporary chin implant is anatomic as its side wings blend along and into the lateral jawline to the sides of the chin.

But as useful as the anatomic chin implant is, it does not augment much of the jawline behind it. It remains a front of the lower jaw augmentation method only.

An extension of the anatomic chin implant is what I call a chin-jawline implant. It is a chin implant that has winged extensions that go back all the way along the jawline…stopping just short of the jaw angle area. This creates greater definition of the jawline although not much width due to the thinness of the extensions.

It is inserted just like any chin implant through either a submental or intraoral incision. A submental incision, however, is preferred as it allows a direct line dissection with long instruments back along the jawline. Despite their aesthetic advantages in properly selected patients, the long extensions offer an opportunity for displacement and asymmetry. Small intraoral incisions can be made to check the most posterior portion of the wings go ensure their smooth positioning along the jawline if desired.

The chin-jawline implant offers enhanced bone definition of the lower lateral border of the jawline. It is useful with jaw angle implants to create a total jawline augmentation effect, to improve jawline definition of a lower facelift and to extend the benefits of chin augmentation. It is available in male and female versions that differ in the shape of the chin with the male being more square and the female being rounded,.

Dr. Barry Eppley

Indianapolis, Indiana

April 29th, 2017

OR Snapshots – Areolar Gynecomastia Reduction

 

Male breast enlargement, known as gynecomastia, presents in various manifestations. While once gynecomastia surgery was most commonly done on teenage boys who developed small (or large) breast mounds that did not recede, today’s gynecomastia reductions are different.

Men are much more particular about the appearance of their chests today and are often intolerant of even the smallest protrusions. A flat chest with a nipple that lays flat is what men seek today. This has led to the most common form of gynecomastia that presents as an isolated areolar protrusion or mound. Known as a puffy nipple, the areolar sticks out from the surrounding skin. In some cases it is just the areola that sticks out and in others the protrusion can be seen to extend beyojd the areolar margins.

Areolar gynecomastia reduction is done through an open excision. The firm lump of breast tissue can not usually be removed by liposuction alone. And even if it could that leaves a small but visible scar on the chest wall on each side. Through an inferior areolar incision, the firm breast lump of tissue is carefully removed leaving a certain thickness of tissue under the areola to prevent an inversion deformity. Often the removal of the breast tissue will expose the pectorals muscle fascia.

The size of the breast tissue that has caused the areolar protrusion its usually very deceiving. The visible elevation of the areolar protrusion seen externally is really just the tip off the iceberg of the total breast tissue mass. Anywhere from a quarter to a fifty cent piece diameter of breast tissue is removed and can be more than a centimeter thick.

Areolar gynecomastia reduction can be done under local, IV sedation or general anesthesia depending upon the patient’s preference. Since it does not involve any excision much behind the areolar margins or liposuction elsewhere on the chest, a drain is not used.

Dr. Barry Eppley

Indianapolis, Indiana

April 28th, 2017

Bra and Breast Implant Cup Size Volumes

 

In breast augmentation surgery women should choose implant size based on the way it makes the breast look. But the obvious question from prospective patients is what cup size will I be afterwards? Ot what implant volume is needed to give the cup size they want? Historically the common answer is that a cup size is about 100cc, more or less based on the size of the patient. The correlation between bra cup size and implant volumes has never been directly studied and compared.

In the May 2017 issue of the journal Plastic and Reconstructive Surgery a paper was published entitled ‘What Is the Standard Volume to Increase a Cup Size for Breast Augmentation Surgery? A Novel Three-Dimensional Computed Tomographic Approach’. The authors used five bra cup sizes from three different manufacturers to assess their volumes using linear measurements, water displacement and volume calculations from 3D CT reconstructions. In addition almost 80 breast augmentation patients were assessed comparing implant volume and patient questionnaires. Their reported results showed that amongst bra manufacturers an average volume of 135cc for each cup size increase was found. In patients the average volume increase per cup size was 138cc.

To no surprises the authors found that there was no standardization of cup sizes amongst the manufacturers studied. The authors conclude that a range of 130ccs to 150ccs is equivalent to a one cup size increase. Narrow bra widths need 130cc while larger bra widths need 150ccs.

While the size of the patient undergoing breast augmentation is well known to affect how the augmented breast will look, it is good to offer patients some general guidelines. Whether it is for a primary breast augmentation or for the patient changing implants for size reasons, the use of a 125cc to 150cc breast implant volume per cup size is vey helpful. For small women it is probably closer to 100cc while for larger women the use of 150ccs is more accurate.

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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