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Posts Tagged ‘breast lifts’

Case Study – Breast Lifts with Implants

Wednesday, March 16th, 2016

 

Background: Severe sagging of the breasts occurs for a variety of reasons but the most common is weight loss. Weight loss creates the unaesthetic combination of excessive stretched out breast skin and loss of breast volume. Occurring together this allows many breast mounds to fall over the inframammary fold carrying the nipple with it. The empty sack of breast skin creates a very deflated breast appearance. While its look may be masked when compressed upward in a bra, its lack of support is very apparent without it.

Breast Sagging classification Dr Barry Eppley IndianapolisSevere sagging or Grade III breast ptosis always requires a full breast lift to get the breast mound and nipple back up on the chest wall. A full breast lift is an anchor pattern procedure with the result scars appearing like its description. It is identical to the breast lift component used in a breast reduction procedure. An implant is always needed for some degree of volume restoration and to create support to hold the breast lift up.

The combination of a breast lift with an implant, the so called implant mastopexy, is always a difficult procedure to perform and get consistently pleasing results. This is because the two aesthetic breast procedures fight against each other. The breast lift tightens and make the enveloping breast skin smaller. While the role of the breast implants is to push out and expand the overlying breast tissues. These two opposing forces can make it challenging to get the right combination of implant size and degree of breast lift. When one factors in the issue of secondary tissue relaxation after any lift, the naturally ‘stretchy’ nature of the breast tissues in the weight loss patient, the normal risks and complications that come from breast implants and that every woman has two breasts that ideally should match, it should be no surprise that the revision rate on this type of aesthetic breast procedure is significant.

Case Study: This 47 year-old female was bothered by the very saggy appearance of her breasts. While once having much larger breasts significant personally-induced weight loss caused her breasts to deflate and severely sag. She passed the ‘pencil test’ with flying colors. (placing a pencil under her breasts and it stays in place) She had a full Grade III ptosis with the right breast hanging lower than the left.

weight loss BAM LIft results front view Dr Barry Eppley IndianapolisUnder general anesthesia and using preoperative markings made in the standing position, a full breast lift was performed. The bottom part of the lift was left open through which anatomic shaped silicone breast imlpants of 450cc size were placed in the partial submuscular plane.

weight loss BAM Lift results oblique view Dr Barry Eppley Indianapolisweight loss BAM Lift result side view Dr Barry Eppley IndianapolisHer three months postoperative results show dramatic improvement in her breast shape and size. While her breast mounds appear to be in good position at this point after surgery, I would not judge the final result until six to nine months when full tissue relaxation has occurred. I would anticipate some residual drop of the breast mounds to occur over the implants with further tissue settling.

While early combination breast lifts and implant result may be very acceptable, the poor quality of the breast skin/tissues will inevitably make for some secondary tissue sag off of the implants. Whether that will be enough to bother the patient is a personal decision. But it is wise in combination breast lifts with implant surgeries to anticipate the potential need for a revisional surgery.

Highlights:

1) Severe sagging of the breast always has the nipple located below the inframammary fold and is associated with significant breast tissue loss.

2) Full anchor style breast lifts are needed with Grade III ptosis and an implant to restore volume to the elevated breast mound.

3) The revision rate for combined full breast lifts with implants in Grade III ptosis is as high as 50% or more due to secondary tissue relaxation of the overlying breast mound.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Small Saggy Breasts

Friday, January 1st, 2016

 

Background: Breasts that are either deflated or have developed sagging are prime reasons to pursue breast augmentation surgery. Pregnancy and weight loss are the most common culprits for causing this type of breast shape change. Breast augmentation surgery is the solution to these breast shape concerns.

With loss of the supporting breast volume combined with stretched out skin, the breasts not only get smaller but that likely will develop some sagging as well. While breast sagging occurs in a variety of degrees of magnitude, these degrees of sagging are definjed by where the nipple sits relative to the inframammary fold. The relevance of this to the breast augmentation patient is whether their breast sagging will require some type of lift with their implant placement or not.

The most difficult breast sagging patient is the one whose nipples are right at the level of the inframammary fold. This makes them marginal for whether they can just have breast implants alone. Will the implant volume create enough of breast mound and nipple elevation to avoid the need for a breast lift? Two factors play into whether this is possible, the implant volume’s and the potential for lowering the existing inframammary folds.

Case Study: This 24 year-old female wanted breast implants. She was very small framed and thin and had two pregnancies. As a result, she had lost all of her breast tissue and the stretched out skin had a little sag.

KA Breast Augmentation results front viewKA Breast Augmentation results oblique viewUnder general anesthesia, she has smooth round high profile silicone breast implants of 400cc size placed. Through an incision placed lower than her existing inframammary folds, a dual plane partial submuscular position was made which also lowered the fold levels as well.

KA Breast augmentation results side viewWomen who are marginal candidates for needing a breast lift can avoid this undesired possibility by a combination of an adequately sized implant and dropping down the level of the lower breast folds. There is also some risk of developing bottoming out of the breasts but this must be balanced with how much one wants to avoid the scars from a breast lift procedutre.

Highlights:

  1. Breast implants can adequately ‘reinflate’ breasts as long as they do not have appreciable breast sagging.
  2. In many mild cases of breast sagging, the inframammary folds must be lowered to get the implants adequately centered behind the nipples.
  3. The size of the breast implant chosen will determine how well any breast sagging and excess breast skin is filled out.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Lifts Cause A Drop In Bra Cup Size

Sunday, July 13th, 2014

 

Breast Sagging and Involution Dr Barry Eppley IndianapolisSagging of the breasts is a common development for most women due to aging, pregnancy or weight loss. It is most severe with multiple pregnancies or significant amounts of weight loss. While corrective breast lifting is most frequently performed with  implants to restore and even increase original breast volume, it can also be done alone when the woman requests to just ‘put them back where they once were’.

Many women assume that a breast lift will also make their breasts more perky as well as fuller in the deficient upper pole. While this may be true for some women who have more sagging than breast tissue loss or a lot of volume that has fallen over the inframammary fold, this is not necessarily so for most women with breast sagging.

Breast Lifts Make Breast Appear Smaller Dr Barry Eppley IndianapolisIn the July 2014 issue of the Plastic and Reconstructive Surgery journal, an article was published entitled ‘The Impact of Mastopexy On Brassiere Cup Size’. This article was a clinical study that evaluated the change in bra cup size in women who had undergone breast lifts. Over a nine year period from the perspective of a single surgeon, twenty women who had underwent mastopexy alone (breast removed less than 150 grams per side) were surveyed regarding before and after surgery cup size, changes in bra manufacturer and weight gain/loss. The majority (80%) had grade II ptosis while the remainder had Grade III. Average breast tissue removed was almost 60 grams. (minimal) Average change in bra cup size was a decrease of 1.05 cup sizes.

This study demonstrates what plastic surgeons know based on a lot of observational experience…a breast lift will make one’s breasts look smaller. They will be more uplifted and have variable degrees of perkiness but they will be smaller both by appearance and in actual bra cup size. This occurs because in most cases of breast sagging the actual breast volume is less than the actual cup size a woman is wearing. This phenomenon is often called the ‘rock in the sock’ effect as the skin sleeve is bigger than what is inside of it. But when the breast is lifted and tightened, the bra cup size usually decreases despite teh fact that little to no breast volume has been removed.

As this study shows, breast lift surgery alone results in an average drop of one bra cup size. This is important to preoperatively appreciate as maintaining the same breast volume (or to even end up slightly bigger) may require an implant to be combined with the lift.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Lift with Implants for Postpartum Sagging

Monday, May 19th, 2014

 

Breast Sagging after Pregnancy Dr Barry Eppley IndianapolisBackground: Loss of breast volume and resultant sagging is a common sequelae of pregnancy. The more pregnancies a woman has the more the breasts will sag. The sag is a function of loss of volume (like a balloon deflating) and increased skin and loss of its elasticity. (the lining of a balloon gets bigger) Such breast effects are magnified in the woman who initially had fairly large breasts during her teenage and early adult years. In essence, the bigger the breasts the more they can deflate and sag.

It is a common misconception amongst some women that implants can lift up a sagging breast. This is true if the breast sag is more inward than downward. If the nipple remains just at or above the inframammary fold (IMF, lower breast fold), then an implant will truly lift it up through a volume expansion effect. However if the nipple is at or below the inframammary fold (lower breast fold), volume expansion will actually make the sag worse because it drives the nipple downward not up.

Breast lifts are needed when implants are placed to move the nipple and the attached breast mound up onto the face (in front of) the implants. The only two lifts that are truly effective in the sagging breast are the lollipop (vertical) and anchor (combined vertical and horizontal) type breast lifts. Which one is needed depends on the degree of sagging and how much volume (implant size) is being added. Often the need for the horizontal excision and scar line is not known until the surgery is being done through the tailor tack method of executing the lift.

Case Study: This 31 year-old female wanted to improve the size and shape of her breasts. She had D cup breasts when she was younger but that changed after having two children. Her breasts had become nearly two sacs of hanging skin with less than 1/3 of their original breast volume. She wanted her breast volume restored with a good implant size.

Breast Lift with Implants result front view Dr Barry Eppley IndianapolisUnder general anesthesia, a vertical breast lift outline was initially incised and de-epitheliazed. Through the lower end of this excision, a tunnel was made into the submuscular plane and implant sizers were inserted and inflated to 550ccs. The nipple and the breast mound was then lifted up to the center of the recreated mound and the surrounding breast skin tacked together with staples beneath it into a completely vertical line down to the fold with a small horizontal extension. The skin within the staple line was then excised and closed. Prior to the closure near the fold, the sizers were replaced with 550cc silicone gel high profile implants.

HD Breast Lifty with Implants result oblique view Dr Barry Eppley IndianapolisHer recovery was no different than that of the typical breast augmentation patient. A breast lift adds no extra pain or swelling to the recovery process. It does longer for complete incisional healing due to their length and the number of sutures needed to close it beneath the skin.

Breast Lift with Implants result side view Dr Barry Eppley IndianapolisThe combination of a breast lift with an implant (known as an augmentation mastopexy) is commonly needed when many women present with sagging breasts. While it is a very effective breast reshaping procedure, it combines the risks of both separate operations. This makes the need for revision as high as 30% in most large studies that have evaluated the outcomes for this operation. It is a very artistic operation that requires judgments during surgery balancing implant size with the amount of lifting needed.

Case Highlights:

1) Significant loss of breast tissue with sagging after multiple pregnancies is a common result in women that initially had large breasts.

2) An implant alone in severe breast sagging will actually aggravate the sagging not help it.

3) Combination breast lifts with implants is a challenging operation that must balance the patient’s desire between volume augmentation and the amount of lift needed to correct the sagging.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Augmentation without a Lift in Sagging Breasts

Monday, March 31st, 2014

 

Background: One often under appreciated aspect of breast augmentation with implants in some patients is that what will occur is that the existing shape of the breast merely gets bigger. Breast implants do not possess magical properties and they can not cure all ills of one’s breast shape issues. This is why it is critical to carefully assess the breasts before surgery to point out and plan any concomitant techniques to address what an implant can not do or to provide a realistic understanding of what the outcome will be.

Breast Sagging classification Dr Barry Eppley IndianapolisThe biggest patient misconception about breast implants is that they are capable of lifting up sagging breasts. The reality is that nothing could be further from the truth. A minor lifting effect can occur if the nipples are at the level of the inframammary folds. But in real breast sagging or ptosis, where the nipples are below the inframammary folds, breast implants will actually exacerbate the problem not make it better. (type 1 or 2 breast ptosis)

But many women understandably do not want the scars from a breast lift even if they may really need it for their breast augmentation. There is certainly no harm in not doing a breast lift in implant augmentation of sagging breasts as long as one has a full appreciation of what the breasts will look like afterwards. The nipples will not be centered on the breast mound, the implants will look too ‘high’ and the breast tissue may appear to be hanging off of the lower half of the implant.

Case Study: This 26 year-old female came in for breast augmentation after having had two children. She had a grade I/II breast ptosis with a low positioned breast mound and nipples that were just below the inframammary fold. She was offered a vertical breast lift with her augmentation but she did not want the scars that would result from it. She stated she only cared how she would look in a bra or swim suit.

Breast Augmentation without Lift result front viewUnder general anesthesia, she had 550cc high profile silicone implants placed through incisions below her existing folds. The implants were placed in a partial submuscular dual plane location. It could be seen on the operating table that her nipples were not centered on the breast mounds after the implants were placed even though the inframammary fold was lowered as much as possible.

Breast Augmentation without lift result oblique viewHer postoperative result showed what was expected…the implants looked ‘high’ because the nipples and the breast mounds were more on the lower half of the implant rather than centered over it.

Breast Augmentation without Lift result side viewThe relevance of this breast augmentation case is to demonstrate the consequences of not doing a breast lift with implants when one is really needed. One has to choose between a better shaped breast with scars or a scarless breast augmentation result that is far from an ideal shape. The good news is that one can always do a lift later if one eventually decides that scars are a better aesthetic trade-off than this type of augmented breast shape result.

Case Highlights:

1) The shape of the breast, particularly sagging, can adversely affect the outcome of breast augmentation surgery.

2) Contrary to popular perception, breast implants do not have any substantial lifting effect on a sagging breast.

3) The aesthetic tradeoff for augmenting a saggy breast without a lift is a very full upper pole and a low nipple position.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review – Refine Soft Tissue Suspension System

Wednesday, September 11th, 2013

 

The ideal youthful breast has fullness in the upper pole, does not sag, and has a slightly pendulous lower pole. The slope of the upper pole should be slightly convex, straight, or slightly concave. With time, and gravity, many women lose that nice fullness in the upper pole, aging the breast and making it less attractive. In order to combat this problem, plastic surgeons have tried many different techniques in order to reestablish or make upper pole fullness.

The Refine internal suspension system is a new device that has been developed an use with this problem in mind. The Refine system is a soft and flexible suture-mesh-anchor system that provides the soft tissue with internal support. It is made from medical grade polyester. It has been FDA approved and is indicated for the reinforcement of soft tissue.  The Refine system is placed percutaneously using specialized needles and is a two part system. The first part is the anchor utilizing a small piece of flexible mesh which is placed just deep to the pectoralis fascia. The second part using anchors which engage into the soft tissue, lifting the tissue up.  The two parts are then secured together, burying the knots deep in the soft tissue of the breast.

The most common use of the Refine system is for breast lifts in order to maintain upper pole fullness. When performing a breast lift or a breast reduction, with time, the breast tissue settlesor bottoms out and loses that upper pole fullness that many women want. By using the Refine system, plastic surgeons can permanently lift the breast tissue, maintaining that fullness for a more youthful look. The Refine system is not palpable and cannot be seen on mammography.

Plastic surgical experiences with the Refine suspension system in the breast have been promising and results have been maintained. Overall complications from this device seem to very low and patients report minimal discomfort after placement. This is an exciting new tool for plastic surgeons that is optimally used in conjunction with other breast procedures such as reductions, lifts and with fat injection breast augmentations.

Dr. Barry Eppley

Dr. Jane Namkung

Indianapolis, Indiana

Plastic Surgery Product Review: GalaFLEX Mesh

Saturday, April 27th, 2013

 

Numerous plastic surgery procedures involve tucks and lifts to achieve their effects. While many intraoperative techniques are done to tighten and support lifted tissues, no such result is permanent. Tissue relaxation and stretching and the effects of gravity work almost from the first day after surgery to undue some of the achieved result.

While tissues may be tightened and reinforced, their inherent lack of thickness or structural weakness may not provide optimal support. This is where the role of an implantable mesh material has always been appealing. But the use of traditional polymer meshes when placed right under the skin have a long history of potential complications, most notably palpability, thinning of the overlying tissues and even extrusions.

An appealing reinforcing mesh would be one composed of a resorbable material. This is the role that allogeneic meshes have filled, such as Alloderm and Strattice, which provide a dense collagen material which is fabricated from donor tissues. While very effective, its costs are considerable particularly in bigger pieces.

GalaFLEX mesh composed of a resorbable material that has FDA approval to reinforce soft tissue where weaknesses exist or for use in procedures involving soft tissue repair or other fascial defects that require the addition of a material support to obtain the desired result. Uses in aesthetic plastic surgery could include facelifts, necklifts, browlifts, breast lifts and breast reductions.

GalaFLEX is a flat knitted elastic mesh composed of poly-4-hydroxybutyrate (P4HB) which is from a class of materials known as poly-4-hydroxybutyrate that are produced naturally by bacteria in a recombinant fermentation process. It is a resorbable material that is broken down by water absorption and eliminated from the body as carbon dioxide and water in 12 to 18 months after implantation.

GalaFLEX mesh is of particular interest to plastic surgeons in breast surgery as an inferior pole sling support. Bottoming out of the breasts after breast lifts and reductions is a common aesthetic problem after these surgeries.

Dr. Barry Eppley

Case Study: The Value of Nipple Lifts in Breast Augmentation

Monday, March 4th, 2013

Background: Breast implants are placed in a wide variety of breast shapes. While they will always increase breast size that does not mean an improved breast shape will always result. A key feature of the perception of breast shape is the location of the nipple-areolar complex. It is always most aesthetically pleasing when it is centered on the breast mound. However, there are some breast augmentation patients whose preoperative mound has sagging and a lower than desired nipple-areolar position.

When sagging breast exists, particularly if it is significant, a breast lift is going to be needed with implant placement. There is the perception that implants will lift up a sagging breast but this effect is a relatively minor one. In fact, implants in a sagging breast will usually make it look worse as the increased upper pole fullness drives the nipple-areolar position even lower. But many women who  have mild to moderate sagging do not want the scars of a breast lift when undergoing augmentation.

The nipple lift, also known as a superior crescent mastopexy (SCM), is not a form of a breast lift. It has no ability to lift up the breast mound, it only changes the position of the upper margin of the areola. But in minor amounts of breast sagging, it can help ‘hedge the bet’ against a worsened nipple-areolar position after implant placement.

Case Study: This 44 year-old female wanted implants to fill out her deflated breast mounds after having had children. Earlier in life she had larger D breasts as judged by the width of her breast base mound and the amount of breast skin present. Her nipple-areolar complexes were on the lower half of the deflated breast mound and just at the level of the underlying inframammary folds. She did not have enough sagging to justify any form of a breast lift but there was concern what would happen when implants were placed.

Under general anesthesia, 550cc gummy bear silicone implants were placed in the submuscular position through a lower breast fold incision. At the same time a nipple lift was performed, removing a 15mm segment of skin at the very center of the crescent-shaped excision. This lifted the upper areolar position and increased the diameter of the nipple-areolar complexes as well.

She had the typical breast augmentation recovery which was short as she was placed on early physical therapy. (rapid recovery breast augmentation program). All sutures for the nipple lift closure were placed under the skin so no removal was necessary. Her incisions healed uneventfully and she had implant settling and the final breast shape by one month after surgery.

The nipple lift produces a mild elevation which, in and of itself, has little value in breast shaping. But when done in conjunction with implants, it has value in correcting nipple-areolar asymmetry and in creating a more central nipple position in mild amounts of breast sagging.

Case Highlights:

1) Breast implants have a very minimal lifting effect as judged by the nipple-areolar complex.

2) When the nipple-areolar complex is on the lower meridian of the breast, implants can create a lower looking nipple-areolar position with the increased upper pole fullness.

3) A nipple lift creates a small amount of upward nipple positioning and size increase that may be beneficial in certain breast augmentation patients that have mild preoperative sagging.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Breast Lifts with Implants

Monday, February 4th, 2013

 

Breast reshaping for many women requires a combination of volume enhancement/restoration and lifting of sagging skin and a low nipple-areolar position. Saline or silicone breast implants are placed in a complete or partial submuscular position and various types of lifts are performed on the overlying breast skin envelope. In most cases of significant breast reshaping, a vertical (lollipop) or combined vertical-horizontal (anchor) pattern of lifting is needed.

The following postoperative instructions for breast lifting with implants are as follows:

1.  Most of the discomfort after surgery is related to the submuscular implants and not the breast lifts. Pain medications are prescribed and most patients will need them. You should take them as directed on the label, usually 2 tablets every 3 to 4 hours as needed. After a few days many patients only use Tylenol or Ibuprofen. You may also feel free to use ice packs on your breasts for pain as long as they do not directly contact the breast skin.

2.  You will come out of surgery in a bra with gauze inside of it over the taped incisions. The bra is there for support and comfort. You may develop some spotting of blood onto the outer aspect of the bra the first night after surgery. This is normal and you need not be concerned.

3. You may remove the bra and the gauze inside it and shower 24 to 48 hours after surgery. It is ok to get the tapes wet. They are there to protect the incisions and eliminate the need for any wound care from your standpoint.

4. All breast lift incisions are closed with resorbable sutures under the skin. They are covered with glued on tapes for a week after surgery. Do not remove them. Dr. Eppley will take them off. It is also ok to have them get wet when you shower. Some spotting of blood may appear on the tapes and this is normal.

5. In rare instances, drains may be used after surgery. If so, empty them as needed. You will be given directions how to do so before going home after surgery. They may get wet in the shower. They will be removed in one to two days after surgery in the office.

6. Strenuous physical activities and working out should wait for at least two to three weeks after surgery. You do not want to put undue stress on the healing breast incisions. When you feel more comfortable you may begin working out by walking on a treadmill or on a stationary cycle.

7. You may eat and drink whatever you like right after surgery.  Focus on liquids and soft foods for the first few days after surgery.

8.   You may return to work and any non-strenuous physical activity as soon as you would like based on your comfort level.

9.   You may drive when you feel comfortable and can react normally and are off pain medication.

10. If any breast redness, increased tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Avoiding The Need For A Lift In Breast Augmentation

Sunday, January 13th, 2013

 

The placement of a breast implant is often viewed as being either under the pectoralis muscle or above it. When it comes to being above the muscle in the so-called subglandular position it can only be completely in that position. But when it comes to the submuscular position, a partial or complete placement relative to the muscle border is possible. This partial submuscular implant location is known as the dual-plane in which the bottom half of the implant is located below the muscle in the subglandular plane.

By placing an implant in two simultaneous tissue planes, the lower half of the breast tissue is expanded. This could be very useful in women that present for breast augmentation that have a mild degree of sagging. Breast sagging, known as ptosis, is a frequent confounding factor in breast augmentation. Contrary to popular perception, a breast implant has a very limited breast lifting capability. Only when the nipple is above the level of the inframammary fold can the plastic surgeon be assured that the nipple will end up in the center of the newly enlarged breast mound. But when the nipple is at or lower than the fold, some form of a breast lift will always be needed if the nipple is to be centered on the mound.

In these mildly sagging breasts is where the dual-plane implant placement approach is useful. One way to get the nipple centered, without a breast lift, is to lower the inframammary fold and increase the volume of the breast below the position of the nipple. To do so, the implant clearly  has to have a portion of it that is below the lower border of the pectoralis muscle.

In the January 2013 issue of the Aesthetic Surgery Journal, a clinical study on the dual-plane approach to breast augmentation in women with mild degrees of sagging was published. Over a period of eight years, a total of near 2000 women who underwent primary breast augmentation with either saline or silicone breast implants was evaluated. Of this group 256 patients underwent a dual-plane approach due to their existing breast ptosis. Their findings show that the dual-plane breast augmentation approach is best used for those patients that have minimal ptosis. In other words, those women that fall into the gray area of whether they should have a traditional breast implant approach or may need some form of a breast lift.

I have used the dual-plane approach for years and do find it to be useful when placing breast implants in women with mild ptosis/ (nipple at the level of the inframmary fold) One other technique that can accompany the dual-plane approach in these patients is to also do a simultaneous nipple lift. (superior crescent lift) This is a great way to hedge your bet so to speak to get the nipple as high up on the breast mound as possible. This combination will work most of the time to avoid breast lift scars in these ‘tweener’ patients.

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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