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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘buccal lipectomy’

Buccal Lipectomy Misconceptions

Thursday, April 21st, 2016


One of the techniques to help create a thinner face is that of a buccal lipectomy procedure. Because it is the largest collection of encapsulated fat on the face and its extraction is a straightforward and uncomplicated procedure, it is an easy target when it comes to facial slimming efforts.

Despite that the buccal lipectomy procedure has been around for a long time, the effects if its removal are frequently misunderstood. The first misconception is what effect it has on slimming the face. The main portion of the buccal fat pad adds volume primarily to the submalar region of the face. This lies right under the cheekbone where one would put their thumb under the cheekbone prominence. It should not be confused with the malar fat pad, which is directly below the skin of the cheek. It also does not extend all the way down to the side of the mouth or even down to the jowls.


Facial Effects of Buccal Lipectomy Dr Barry Eppley IndianapolisGiven its anatomy, this is why a buccal lipectomy will NOT slim the face from the cheeks down to the jawline. By itself it can not make a round face into more of a V-shape. It simply is not that powerful. This is why a buccal lipectomy is often combined with perioral liposuction to extend its effect further down on the face.

Another more recent misconception is that a buccal lipectomy will eventually lead to gauntness of the face or a prematurely aged look. While this belief does have some partial truth to it, such a facial effect depends on what type of face on which it is performed. Thinner faces that are genetically prone to eventual facial lipoatrophy would be prematurely and adversely affected by removing the buccal fat pads. But in fuller and more round faces (aka heavy face) there is no reason to believe that excessive facial thinning will eventually occur.

Buccal Lipetomy Fat Pad AnatomyThe last misconception is that the buccal lipectomy is an all or none procedure. While large amounts of the buccal fat pad can be removed, that does not mean it has to be. A subtotal or incomplete buccal lipectomy can be done when there are concerns about too much fat removal. There are three lobes or extensions of the buccal fat pad and in a subtotal technique only a portion or just the anterior lobe can be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Lip Fat Injections using Buccal Fat

Thursday, April 14th, 2016


Lip augmentation is a popular facial filling procedure that has been done by a wide variety of materials. Synthetic fillers, fat injection and implants have all be done with well known advantages and disadvantages. The perfect lip augmentation material, however, remains elusive

Of all the known injectable fillers, fat has a high appeal but is the most vexing. Fat is a natural material that is unique to each patient and everyone has enough to harvest to do lip augmentation. But even in small volume placements like the lips, its retention and survival is far from assured. In fact, substantial clinical experience has shown that the lips actually have one of the lower rates of fat grafting success on the face. Whether that is due to high motion activity of the lips or their lack of much native fat tissue is unknown.

The donor site for lip fat injections has been harvested from just about every body donor site imaginable. No one knows if the donor source of fat grafting affects how well the fat graft takes although it is hard to imagine that it does not play some role albeit even if it is a minor one.

Buccal Lipectomy intraop Dr Barry Eppley IndianapolisOne donor source for injectable fat grafting that has not been previously described is that of the buccal fat pad. There is more than enough fat in the buccal fat pads for transfer into the lips. But buccal fat pad harvesting should not be routinuely done due to potential undesired aesthetic tradeoffs of facial hollowing that could occur in many patients. But for those patients with rounder faces that desire facial slimming, a buccal lipectomy can be aesthetically beneficial.

Buccal Fat Injections to Lips Dr Barry Eppley IndianapolisHarvested buccal fat pads can be pass back and forth to create an injectate that can easily be injected through a small blunt-tipped cannula. And for the buccal lipectomy patient who also desires lip augmentation this can be a superb method of fat recycling/redistribution.

Buccal Fat Lip Injections result Dr Barry Eppley IndianapolisDoes fat from the buccal fat pads survive better than other donor sites. The fat is clearly different in being encapsulated and with much larger globules. It is tempting to hypothesize that it survives better than subcutaneous fat, and I suspect that it does, but it remains to be scientifically proven.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of The Buccal Lipectomy in Facial Reshaping

Wednesday, July 29th, 2015

The buccal fat pad is most commonly known because of the aesthetic buccal lipectomy procedure. Its historic significance is in what it creates when it is removed…a facial thinning effect. It is the one facial defatting procedure that is easy to do, effective and permanent. It is not a facial liposuction procedure, as is commonly perceived, but rather an excisional procedure where the fat is teased out and directly cut off and removed.

Despite its historic use more recent concepts of facial aging have cast doubt on the validity of the procedure. Losing facial volume by fat atrophy is one of the sequelae of aging and its toll on the face is that of a devoluminizing effect leading to a gaunt and more aged facial look in many people. This has let to contemporary efforts to maintain or even add fat volume to the face as a restorative procedure. This has led to many plastic surgeons spurning the buccal lipectomy as a procedure that should be avoided and abandoned.

The reality is that the buccal lipectomy is neither a completely good or bad aesthetic procedure. It all depends on the patient’s facial anatomy, shape and desired effect. Understanding the anatomy of the buccal fat pad will shed light on whether it could be beneficial to any patient’s facial reshaping goal.

Buccal Fat Pad AnatomyWhile the merits of the buccal lipectomy can be debated, its anatomy can not. It is a large encapsulated fat pad that has a distinct vascular pedicle that sits right below the cheekbone in the appropriately named buccal space. There is no other such fat collection with this specific anatomy in the face. Besides its size and exact anatomic location it is also not appreciated that it has numerous extensions (fingers) that extend outward and beyond its ‘home’ submalar located buccal space. Its biggest extension heads northward where it can be found around the temporalis muscle. Its location here speaks to what is believed to be its role as an interpositional material between the masseter and temporalis muscles. This allows them to have functional movement without interfering with each other or allowing scar adhesions to develop between the two muscles. What is also clear in the anatomy of the buccal fad pad is that it does not extend downward below about the level of the occlusal plane.

This anatomy has several implications as to the merits and potential deleterious effects of the buccal lipectomy procedure. First, its removal results in a very discrete facial thinning location or indentation which sits below below the cheekbone and is about the size of a thumbprint. It does not have a larger facial thinning effect. It will not create any lower cheek thinning effect like down around the side of the mouth as is commonly believed. Secondly, an aggressive removal of the buccal fat pad (which is easy to do) will result in an adverse thinning effect up into the temporal region. This will result in temporal hollows as the remaining fat pad is pulled down and atrophied from the loss of the ‘mother ship’ so to speak. Lastly loss of the buccal fat pad is permanent and is one of the only facial fat collections that can not be restored by secondary weight gain by fat cell uptake of excess lipids. (although fat injections can be a corrective procedure)

The conclusion based on anatomy is that the buccal lipectomy procedure should be reserved for very specific types of facial shapes and should often be performed in a subtotal or incomplete manner. Only in the fullest and roundest of facial shapes should a more complete buccal lipectomy be done. In less round faces who have a very specific fullness isolated to just below the cheekbone, a subtotal buccal lipectomy can be safely performed. For a more complete facial derounding effect, a buccal lipectomy will need to be combined with other procedures to achieve a maximal facial reshaping effect.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Facial Reshaping by Buccal Lipectomies and Perioral Mound Liposuction

Wednesday, December 31st, 2014


Background: The shape of the face is controlled by a variety of anatomic structures. Its foundation is influenced by the size and contour of the deeper facial bones, the thickness of the muscle and fat that lies above it and the amount and tightness of the overlying skin which envelopes it all. While everyone’s facial shape is unique, there are general types of facial shapes that are well known from oval, oblong, round, rectangular, square, triangular (inverted and heart-shaped) and diamond shape.

While the beauty of any of these facial shapes can be debated, many people find that a more inverted triangular or heart-shaped face is the most aesthetically pleasing. Having cheeks that are more prominent n width and projection that the portions of the face that lie below it is the hallmark of this facial shape. For those with a round face that desire such a facial change, one looks to fat removal to help with this transition.

Facial Fat (Cheek) Compartments Dr Barry Eppley IndianapolisFat removal of the face is not like the rest of the body. It is more localized into various compartments and has multiple motor nerves to consider when doing it. It is also not a high volume or voluminous source of fat that is capable of making by itself dramatic facial shape changes. Historically facial fat removal was associated with the buccal lipectomy procedure which is large volume by facial standards but does not require liposuction to remove. Other more superficial and lower volume facial fat areas exist, such as the perioral mounds, which can only be treated by small cannula liposuction.

Case Study: This 28 year-old female wanted to create a thinner more v-shaped facial shape. While she already had more of an inverted triangular facial shape, she did not like the fullness below her cheeks and by the sides of her mouth.

Buccal Lipectomy and Perioral Mound Liposuction result front view Dr Barry Eppley IndianapolisUnder general anesthesia, high maxillary vestibular incisions of 1 cm length were made below the parotid ducts. Splitting the buccinator muscles exposed the buccal fat pads which were teased out and removed. Through small incisions (3mms) inside the corners of her mouth, after having been initially infiltrated with a lidocaine and epinephrine solution, small cannula liposuction was used to remove fat from the nasolabial fold down to the jowl area. Each side produced about 2 to 2.5 cms of fat from each side.

Buccal Lipectomy and Perioral Mound Liposuction result submental view Dr Barry Eppley IndianapolisIt usually takes about 6 weeks until the full results from these fat removal procedures were seen. The final results of any facial liposuction/fat removal procedure are seen when the treated tissues feel soft with no hard areas, it feels completely normal to smile without stiffness and the overlying skin sensation feels completely normal. (not numb)

Facial fat removal can be effective at reshaping a somewhat fuller face but it can not really take a round full face and make it substantially thinner. It works best in moderately full to thinner faces where small fat reduction volumes make a more noticeable difference.

Case Highlights:

1) Reshaping or thinning a rounder face can be successfully done by specific site fat removal in properly selected patients.

2) A buccal lipectomy removes upper cheek fat while perioral mound liposuction removes lower cheek/jowl fat.

3) These procedures can make a round face less round and a thinner face more defined based on the limited amount of fat that can be removed.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Bichat’s Fat Pad and Buccal Lipectomy Surgery

Tuesday, February 18th, 2014


The buccal lipectomy is a well known procedure that is done in certain patients for a cheek slimming effect. It is unique amongst most fat removal procedures in plastic surgery because it involves removal of fat within a surrounding capsule. (the only other procedure is the removal of the fad pads in blepharoplasty surgery) The buccal fat is a deep pad that is located between the buccinator muscle and the more superficial muscles including the zygomaticus and masseter muscles in the, appropriately named, buccal space. What is actual function is, large as it is, is not really known. It has been described the functions of aiding sucking in infants to facilitating the movement of the muscles it lies between. None of these explanations, however, are particularly satisfying.

Bichat Buccal Fat pad Dr Barry Eppley IndianapolisWhile buccal fat pad removal is controversial today due to the potential long-term risks of excessive thinning and the creation of a gaunt face, the buccal fat pad has an interesting history. It is also often called Bichat’s fat pad and is so named after the famous French anatomist and physiologist Marie Francois Xavier Bichat. While he lived only a short thirty years (1771-1802), he is remembered as the father of modern histology and descriptive anatomy. While he never used a microscope (interestingly he did not trust them) he was able to describe tissues as distinct entities. (muscle, fat etc) Hence the ‘discovery’ of the large buccal fat pad and its four main extensions. (parotid, temporal, buccal and malar) While one could argue some anatomist somewhere would have found it eventually anyway (it is hard to miss when doing facial dissections), in the context of its day over 200 hundred years ago, such anatomic finds were revolutionary.

Dr. Barry Eppley

Indianapolis, Indiana

Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations

Sunday, March 21st, 2010

The cheek or the midface region plays an important role in facial appearance. As one of the five facial bony prominences (brow, nose, chin, and jaw angles are the others), it is actually the most complex. It lacks any sharp angles, is made up of several bones that intersect together and is surrounded by three distinctly different soft tissue regions. While everyone appreciates that a high and strong cheekbone is desireable, it is not easy to quantitate what that should look like unlike chin projection or jaw angle width which can be actually be measured.

Rather than some absolute number, the cheek region is better recognized for what it does for facial shape and width. As part of understanding cheek morphology, one should not forget how the soft tissue below it affects how the bone looks above. Known as the submalar (below the cheek) region, it is affected by the size and prominence of the buccal fat pad. This golf ball-sized fat collection can be surprisingly large and it helps make for a rounder and fuller cheek region appearance. If the buccal fat pad is very large, it can make this area protrude or be quite ‘cheeky’. If this and other facial areas are small or atrophic, the facial shape may assume a more gaunt appearance.

Therefore when assessing the cheek area, the consideration of both bone (malar) and buccal fat (submalar) areas should be done. Implant manufacturers have recently showed an appreciation for this concept by expanding traditional cheek implants to include either (malar and submalar) or both. (combined submalar shells) Combinations of malar and submalar changes can often make for a better cheek result than just a ‘simple cheek’ implant alone. In some cases, cheek bone enhancement and some submalar reduction (buccal fat removal) may produce better cheek highlights. In other cases, submalar augmentation or a combined malar-submalar augmentation may be aesthetically better.

The uniqueness of  each person’s face and their desired cosmetic outcome must be taken into consideration when planning changes in this area. Removal, or more accurately, reduction of the buccal fat pad (buccal lipectomy) is a surgically simple procedure but it’s decision to do so is more aesthetically complex. Through a very small incision inside the mouth opposite the maxillary first or second molars, the buccal fat pad can be gently teased out. When doing at the same time as some type of midfacial implant, it can be done through the same incision. How much one removes is a matter of judgment. As a general rule, it is not a good idea to try and remove all of it. Not only may that be undesireable in facial appearance in the long-term, but there are several buccal branches of the facial nerve which interlace with the multi-lobed buccal fat pad. They exist most commonly on the superficial (outer) aspect of the buccal lobe, away from the area of intraoral manipulation. For this reason, aggressive buccal lipectomies may inadvertently damage these branches. I have never observedfacial nerve injury from a buccal lipectomy procedure but this attests to a more conservative resection philosophy. In uncommon cases with a very full and ‘fat’ face, a more complete buccal lipectomy may be justified. Such an approach works well when ‘fat-reducing or facial thinning’ procedures are being done such as neck liposuction and/or chin or cheek implants.

Conversely, submalar augmentation rather than reduction may be needed to help fill out a thin or gaunt facial appearance. While initially developed for lifting sagging cheek tissues over ten years ago, the submalar implant is much more commonly used to add soft tissue fullness rather than a lifting effect. If the cheek prominence is adequate but the underlying submalar region is thin or ‘sucked inward’ (indented), than an isolated submalar implant may suffice. If the overall cheek (malar and submalar) is too flat or deficient, then a combined malar-submalar implant may be needed.

When considering cheek augmentation as part of an overall facial improvement plan, both the malar and submalar regions must be considered together. Between expanded submalar implant designs and buccal lipectomies,  a more comprehensive approach with satisfying surgical results is now available.

Dr. Barry Eppley

Indianapolis, Indiana

The Myth of Facial Liposuction

Saturday, November 28th, 2009

Liposuction is a very effective method of fat removal. While it can be used in almost any location of the body where there is fat, it does have limitations. And when applied to certain fat areas, it may even have the opposite effect of an undesired result.

The face is one such area where the concept of liposuction is largely more theoretical than practical. While the face does have fat below the skin, it is not easily removed like that in the trunk or extremities. Facial fat is more fibrous and has branches of the facial nerve lying deep to it. There are few very discrete collections which can easily be removed with the exception of the buccal fat pad and some of its numerous extensions.

Plastic surgeons frequently advertise and perform neck liposuction. And while the neck is part of the face, most patients do not think of the neck when they envision the concept of facial liposuction.

When you combine what is contained in the buccal space with the subcutaneous tissues in the neck, these are the only two facial areas where contouring can be done through fat removal. The neck can be liposuctioned while the buccal fat pad can be directly extracted through a small open incision. Removal of any other facial fat areas through liposuction  is not only ineffective but can cause a lot of tissue trauma and prolonged swelling.

When liposuction first became widely used in the 1980s and 90s, facial liposuction was both advocated and written about. It was used to try and reduce facial fullness in the lateral face and even reduce the prominent mound of tissue that develops above the nasolabial fold with aging. It was proven to be ineffective and has since become largely abandoned as a treatment for facial fullness.

For those seeking to reduce their ‘fat’ face or to deround their facial appearance, liposuction is not the answer. It simply can not do what can be done for the circumference of the thigh or the waistline. One cannot deflate the face so to speak.

Improving the shape of a very full and round face does include some fat removal which is accessible, the buccal and neck fat. But fat removal alone is inadequate as it can only change some of the contour. If a full neck is all that bothers someone, then liposuction alone is a good treatment. But for more total facial sculpting and definition creation,  it must be combined with other procedures that bring out or highlight facial prominences such as the chin, cheeks, or jaw angles. Using implants in these facial convexity areas can help bring shape to an otherwise amorphous face.         

Dr. Barry Eppley

Indianapolis, Indiana


The Psychology of Structural Facial Surgery – Changing One’s Look

Tuesday, November 17th, 2009

Making changes to one’s face is always a big consideration that requires a good deal of thought from surgeon selection to the final choice of operation(s). While there are lots of facial procedures to consider, they can be divided into those operations that treat aging changes (skin and soft tissue sagging) and those that can change structural shape of the face. (bone and cartilage)

From a psychological standpoint, these two facial procedure categories are not the same. Reversing aging changes of the face is about making one look younger…turning back the clock so to speak. Facelifts, blepharoplasties, and browlifts, for example, aim to return one to something that is familiar…a younger you.  That is an easy decision to make for most. The desire to return to what once was is deep seated. The biggest fear in anti-aging surgery is that the operation may be overdone and look unnatural. (not like oneself)

Structural changes of the face, however, pose different psychological considerations. Rhinoplasty, facial implants, and any facial bone changes head one to something unfamiliar…a changed face and a new look. This can create much greater uncertainty because one doesn’t always know what to expect. While one may have a great desire to improve one’s appearance, there is always the trepidation that one won’t like it or it may not turn out well…and then forever be stuck with it. These concerns are magnified in that many of these procedures are often done in younger patients whose sense of self-image is less established and more fragile.

Structural facial changes are usually done in one or two areas at a time This is most commonly seen in rhinoplasty alone or rhinoplasty in combination with chin augmentation or other facial implants. Making a male’s face more masculine or defined often involves the trifecta of structural facial surgery… chin, cheek, and jaw angle implants. Derounding the face usually involves neck and buccal fat removal with a chin implant for women, men may get jaw angle implants as well.

In my Indianapolis plastic surgery practice, I have seen numerous patients over the years who have come to me because they were unhappy with the results of their structural facial surgery done elsewhere. In listening to their concerns, it has become clear that in some cases there was a fundamental misunderstanding or miscommunication about objectives. Sometimes it was the ‘wrong’ operation for their concerns. (e.g., treating submalar and lateral facial concavity with jaw angle implants) Other times, it was an operation that was over- or underdone. (e.g., too large a facial implant or a nose that didn’t have enough of a change) Most of the time, their operations were done well…but the patient’s aesthetic target was missed.

While no plastic surgery operation is an exact science, one’s objectives prior to surgery should be. The use of computer imaging is absolutely essential for structural facial surgery. This is a critical method of visual communication that often unravels the specifics of a patient’s objectives. Looking at combinations of procedures and amounts of changes can almost always avoid an unexpected outcome. While predictive computer imaging is not a guarantee of outcomes (I think of it as Photoshop plastic surgery), it does put the plastic surgeon and the patient at least on the same page.

When considering any form of facial structural surgery, it behooves the patient and the plastic surgeon to meet for several consultations. Computer imaging plays a vital role in setting the surgical plan and helping with postoperative expectations. The emotions and psychological implications that come with forever changing one’s facial appearance is a high stakes proposition that should not be taken lightly. This type of facial surgery is associated with much higher rates of patient dissatisfaction than with more commonly performed anti-aging procedures.    

Dr. Barry Eppley

Indianapolis, Indiana


The Anatomy of the Buccal Lipectomy

Saturday, November 15th, 2008

I frequently get asked by patients in consultation or online what they can do to make their face look thinner. Besides the obvious answer of weight loss for some patients, they are specifically asking about facial fat removal either through liposuction or removal of the buccal fat pads. While liposuction can make a great difference in the neck, it is not a good method for removal of fat in the face. This has been tried a lot in the past and all that usually happens is a lot of swelling with little to no results. So that leaves the buccal lipectomy procedure as the only true fat removal procedure of the face.

What is a buccal lipectomy and what can it really do? The term, buccal, means cheek and we are talking about a very distinct collection of fat that sits right under the cheek bones in the appropriately named buccal space. It is situated between the cheek skin and the cheek lining inside the mouth. It is a very large fat collection, about the size of a golf ball, and actually has fingers of fat that go beyond the cheek into other areas such as the temples. It does provide fullness to the cheek area but is not responsible for fullness at the level of the corner of the mouth or beyond. The exact reason we have this buccal fat is not really known but most believe it serves as cushioning between the chewing muscles.

Removal of the buccal fat pad is really quite easy through a small incision inside the mouth. The fat is easily teased out and a surprising amount can actually be removed. How much to remove is a matter of judgment. If the patient has a really full round face, I will try and remove as much as possible to create an effect that can be seen through their thick overlying skin. You have no worries that you will make them too ‘thin’. In thinner people one has to be careful to not remove too much for it is possible to give someone a very gaunt or hollowed look months or years after surgery. Certainly in a very thin face, this procedure should not be done.

The results from a buccal lipectomy is to create a flattening or indentation of the area beneath the cheek bones. This effect is mimicked by the application of makeup that women use to contour the cheeks. (darker makeup underneath the cheek bone) While this helps thin out or narrow this part of the face, other procedures are usually needed to create an overall facial change that makes it appear thinner, such as liposuction of the neck and chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Improving the Shape of the Face by Bony Augmentation and Fat Reduction

Thursday, October 9th, 2008

Making a face more square or angular can be done through bone augmentation, fat reduction, or both. I have found that there are two types of patients who come because they want a more defined facial look. First is the male patient (usually younger)who does not necessarily have a full or fat face but wants more definition at the defining points of the face. In some cases, I call this seeking the ‘male model look’. The second type of patient is male or female who does have a fuller face and simply wants to be ‘less round’. Their goals are not quite so precise as the first patient. Usually they are younger as well but can be middle-aged also.

The defining bony points of the face are the cheeks, chin, and jaw angles. Facial fat points are the cheeks and neck. Those searching for the ‘male model look’ are usually looking at the trio or combination of cheek, chin and jaw angle implants.  The thinner the face is, the more profound the result will be with this triple implant approach. When you are placing three implants, or simultaneously changing three facial prominences, it is always best to not to overdo it. Large implants in all three places can create a very unnatural or artificial look. Cheek implants never look too good if they are too large.  Subtle cheek changes are more natural.The proper size of a chin implant is easier to know because the amount of chin deficiency can be measured in profile. Most men should consider a more square chin implant style as that is often what this type of patient is trying to achieve. Jaw angle implants can rarely be too large as they are manufactured small anyway and the jaw muscles and thickness of tissue over the jaw angles can camouflage a great deal of the implant.

Those trying to deround a face must use a different approach. Fat removal in the neck (liposuction) and in the cheeks (buccal lipectomies) are an important element of derounding and is often done with a chin implant. In rare cases, cheek implants may be considered but they should be small as buccal fat removal will create the visual impression of some minor cheek augmentation as the area below the cheek moves inward. This type of facial derounding is more subtle than squaring a face with the most dramatic changes occurring in the neck and less in the cheek and side areas of the face.

Careful analysis of the face prior to surgery through computer imaging can be invaluable in this type of surgery. Changing multiple areas of the face at one time, with the objective of changing one’s facial look, requires good insight and understanding between the patient and their plastic surgeon.

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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