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Posts Tagged ‘sliding genioplasty’

Case Study – Four-Piece Total Jawline Augmentation

Sunday, December 20th, 2015

 

Background: The desire for a more pronounced and visible lower jawline exists in both men and women. The surgical methods to do so are more commonly requested by men particularly when it comes to a substantially larger jawline change. Making a jawline more evident focuses on increasing the size and shape at its ‘corners’, that of the projecting chin and the back ends at the bilateral angles.

When creating a total jawline augmentation effect, there are two basic approaches.  The historic and still most commonly used method is a three implant approach of independently placed chin and jaw angle implants. In some cases the chin implant may be substituted with a siding genioplasty. The newer method of jawline augmentation is the fabrication and placement of a one-piece custom made jaw implant that wrap around the chin from angle to angle. It is the preferred method of total jawline augmentation given the preoperative designing of the implant and its smooth one-piece construct. But cost considerations may lead some patients to still undergo the classic three implant method.

Chin and jaw angle implants exist in standard styles and sizes. While for some patients these historic standard chin and jaw angle implant styles will effectively work, newer implants styles offer improved total jawline augmentation results for many patients. Newer vertical lengthening jaw angle implants have allowed for increased visible angularity of the back part of the jaw. When vertical elongation of the chin is needed either newer vertical lengthening chin implants can be used or the historic approach of an opening sliding genioplasty. When significant vertical and horizontal chin augmentation is needed, chin implants and a sliding genioplasty can be combined.

Case Study: This 25 year male wanted a total jawline change. Not only was his lower jaw horizontally short but it was vertically deficient as well. This was evident in the short chin and large overbite which are directly related. When he opened his mouth slightly the improvement in his chin and jaw height could be seen confirming the needed vertical dimension of his chin and jawline.

Chin and Jaw Angle Jawline Augmentation result side viewChin and Jaw Angle Jawline Augmentation result oblique viewUnder general anesthesia, he had an opening sliding genioplasty (7ms done and 7mms forward) with a chin implant overly (5mm horizontal augmentation) done through an intraoral approach. Through posterior intraoral incisions jaw angle implants that added 7mm vertical length and 5mm width were placed.

At one year after surgery the improvement in his jawline could be appreciated. Ideally longer vertical lengthening jaw angle implants would have improved his result and are being considered. The sliding genioplasty and chin implant overlay produced a satisfactory improvement to the front part of his jawline

Total jawline augmentation can be effectively done using a non-custom implant approach. It can require the thoughtful application of newer chin and jaw angle implant styles and the selective use of sliding genioplasty techniques.

Highlights:

  1. Total jawline enhancement consists of front (chin) and back (jaw angle) augmentation.
  2. Preformed chin and jaw angle implants is the historic and standard approach to total jawline enhancement.

3. Vertical chin augmentation in total jawline enhancement can be done by a combined sliding genioplasty with a chin implant overlay.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Sliding Genioplasty and Chin Implants

Tuesday, November 24th, 2015

 

A sliding genioplasty is a very versatile chin reshaping procedure that has been used for decades. In elective chin augmentations it is the alternative option to the use of a chin implant. Although chin implants are by far more commonly done in a ratio of at least 20:1 if not greater. While chin implants are a simpler procedure they are not appealing to everyone nor are they always the best choice for every type of chin deficiency.

A sliding genioplasty is usually best done for younger patients who have significant chin deficiencies. There also is a much higher tendency to  them at the time of orthognathic surgery when other facial bones are being manipulated as well. In larger chin deficiences moving of the bone has less potential for any long-term problems than does an implant.

The limits of how far forward a sliding genioplasty can move the chin horizontally is a function of the thickness of the chin bone. It is important to maintain some bone contact between the upper and lower chin segments, meaning the back edge of the downfractured chin segment should at least touch the front edge of the chin bone above it. (and be stabilized by plate fixation)

Sliding Genioplasty Chin Implant Combination Dr Barry Eppley IndianapolisBut in some larger chin deficiencies even maximal forward chin bone movement may still leave one with less than an ideal profile change. In these circumstances, whether recognized during the initial sliding genioplasty or afterwards, the solution can be a chin implant. A chin implant can be placed on the front edge of the sliding genioplasty to gain an additional 3 to 5mms of horizontal chin projection. An extended anatomic chin implant is used so that its wings cover the step off area on the back side of the osteotome line. It is critically important that the chin implant is secured by screw fixation to the sliding genioplasty segment.

While chin implants and sliding genioplasties are traditionally thought of as being mutually exclusive, they do not have to be. In need of extreme amounts of chin projection, the combination of a sliding genioplasty with a chin implant overlay can be a useful chin augmentation strategy.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Recycled Medpor Chin Implant in Sliding Genioplasty

Saturday, June 13th, 2015

 

When a chin implant ‘fails’ it may be replaced or revised by a sliding genioplasty. Chin implant failure can usually be defined as an implant that had not met the patient’s aesthetic desires due to design, size or positioning issues. This is most commonly seen when a chin implant is used for larger chin deficiencies whose horizontal and vertical dimensional needs are at the fringe or beyond what a standard performed implant can achieve. Recurrent chin implant problems such as asymmetry and visible or palpable edges are another indication to consider moving from a synthetic to an autogenous or more natural chin augmentation solution.

Medpor Chin Implant Removal Dr Barry Eppley IndianapolisMedpor is a chin implant material, which while used far less than that of silicone chin implants, is a favorite among some patients and surgeons. While it is a biomaterial that does offer good tissue adherence and fixation it can suffer the same chin implant problems that silicone implants do. The material composition does not make it immune to similar aesthetic issues. While many surgeons state that Medpor facial implants are impossible to very difficult to remove that perception is a relative one when they are compared to silicone. I have removed many Medpor facial implants and they all can be removed in their entirety with careful surgical technique. They rarely come out as one piece by rather in multiple smaller sections.

Medpor Chin Implant Removal and Sliding Genioplasty Dr Barry Eppley IndianapolisMedpor Implant in Sliding Genioplasty Dr Barry Eppley IndianapolisWhen a sliding genioplasty is used to replace a chin implant, it is sometimes more prone to having a ‘step’deformity’ than that of an implant. The aesthetic consequence of this step and the merits of filling it in can be debated. But should the surgeon choose to do so, it can be filled in with a wide variety of materials. A cost effective approach of filling in the step deformity of a sliding genioplasty is to ‘recycle’ the removed chin implant material. With a Medpor chin implant this would be placing the multiple pieces of the implant material that became that way from removal. Since this implant material already has tissue ingrowth on it it can be come quickly ingrown with further tissue, thus serving as an ‘autoalloplast’ so to speak.

Having used recycled Medpor chin implants in over a dozen sliding genioplasties no infections have occurred and the step has been aesthetically covered eliminating the risk of a much deeper labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty Step-off Removal for Smoother Jawline

Monday, June 1st, 2015

 

A sliding genioplasty is a well known chin reshaping procedure. In its original and most traditionally perceived form, it is a bone cut that allows the downfractured bony chin segment to be moved forward. This creates at the front edge of the chin a stair step bone shape after the lower chin segment is moved forward. The length of this stair step is the exact amount in millimeters that the chin is moved forward.

Genioplasty Step Off Dr Barry Eppley Indianapolis3D CT Scan of Genioplasty Stepoff Deformity Dr Barry Eppley IndianapolisWhat is also known but less appreciated is that there can be a bony step off at the back end of the osteotomy cut. As the back end of the downfractured chin segment moves forward it can leave an inverted V-shaped deformity along the inferior edge of the jawline. How significant this residual notch deformity is depends on the angle of the chin osteotomy line and the amount of its horizontal forward movement. Probably the angle of the bone cut is more significant than the amount of forward bone movement. This can easily be seen on lateral cephalometric or 3D CT scans in some postoperative sliding genioplasty patients.

Genioplasty Step Off Removals Bone Segments  Dr Barry Eppley IndianapolisFor those patients that are bothered by the jawline notch deformity after a sliding genioplasty, it can be reduced or removed. The question is whether the notch should be filled in or whether the bone behind the notch should be removed to make it smooth. There are arguments to be made for both approaches. But the bone removal approach offers the most direct and assured method to obtained a smoother jawline while avoiding the use of implanted materials. Through a small submental incision, the prominent bulges off bone can be removed along the jawline by a reciprocating saw cut. This usually exposes the marrow of the bone which is covered by a hemostatic resorbable material. The submental incision usually heals very well and offers a slightly more rapid recovery than using an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Hydroxyapatite Block Grafting in Sliding Genioplasty

Sunday, May 24th, 2015

 

A sliding genioplasty is the autologous alternative to using a chin implant. It is done far less frequently than using implants for chin augmentation, and it should be, but it does have a defined role for lower facial augmentation. It is indicated for large chin movements which standard implants can not achieve, for young patients who need large amounts of chin augmentation and for existing chin implants that have developed complications.

Labiomental Fold Dr Barry EppleyA sliding genioplasty involves a bone cut below the anterior tooth roots and mental foramen which is done at various angles depending on the type of dimensional bone movement needed. As the bone moves forward it is important to appreciate that the labiomental fold will not move with it. The labiomental fold or groove, which is situated about 1/3 the distance from the lower lip to the bottom of the chin, is a fixed structure that is reflective of the attachment of the mentalis muscle to the chin bone over the incisor tooth roots. Its deepest part correlates to the depth of the vestibule on the inside of the lower lip.

Hydroxyapatite Block in Maxillofacial Surgery Dr Barry Eppley IndianapolisHydroxyapatite Prorosity Dr Barry Eppley IndianapolisAs the chin bone comes forward with a sliding genioplasty, the labiomental fold ‘stays behind’. Thus it will get deeper with horizontal chin bone movements. This is due to the now ‘step’ shape of the chin which allows the lower part of the labiomental fold to stay where it is but the chin tissue beneath moves forward.  One historic effort to deal with the deepening labiomental fold effect in a sliding genioplasty is to graft the step of the osteotomy. Many materials have been advocated and used but the hydroxyapatite block graft is one of the most historic. They have long been used in maxillofacial surgery as an interpositional or onlay graft which offers excellent biocompatibility due to its inorganic mineral content and interconnected material porosity.

Hydroxyapatite Block Sliding Genioplasty intraoperative view Dr Barry Eppley IndianapolisHYdroxyapatite Onlay Block in Large Sliding Genioplasty Dr Barry Eppley IndianapolisA carved hydroxyapatite block to fill the step of a sliding genioplasty is an excellent graft choice. Its benefits are when the sliding genioplasty movement is significant, usually 10mms or greater where a large bone step is created. Part of the bone is covered in the midline by the fixation plate but the hydroxyapatite block is placed on top of it regardless. Bone will grow around the fixation plate and into the block.

Grafting the bone step of the sliding genioplasty is not the complete cure for preventing the deepening or for the treatment of the deep labiomental fold. It does, however, have some benefit and is a simple and uncomplicated adjunct to the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Geniopasty with Indwelling Chin Implant

Sunday, May 3rd, 2015

 

Background: Horizontal chin augmentation can be done using either a synthetic chin implant or a sliding genioplasty. There are advantages and disadvantages with either approach and they must be considered in an individual patient basis. The decision in any patient ultimately depends on their perception of an alloplastic vs. an autogenous approach, the risks of the procedure and its recovery and what other dimensional changes of the chin that are needed beyond just that of the horizontal change.

But the use of a chin implant does not always produce the desired amount of chin augmentation change that every patient desires. This may be due to inadequate implant selection, the chin implant settling into the bone thus losing some horizontal projection, chin implant malposition or an accommodation to the initial chin augmentation result.

When further improvement is desired after an initial chin implant augmentation, the options are either a larger implant or to convert it to a sliding genioplasty method. A larger implant is usually done as this is the simplest revisional approach provided that a new implant can create the desired horizontal change. When a larger chin implant offers but a modest additional augmentation (e.g., 5mms or less) the the sliding genioplasty option becomes a consideration. It would be either that or have a custom chin/jaw implant made.

Chin Implant Settling (Erosion) Dr Barry Eppley IndianapolisCase Study: This 26 year-old male wanted additional chin augmentation after having a prior chin implant placed several years previously. He always felt that is lower jaw was smaller. His original chin implant provided 7mms of horizontal projection but it could be seen that it had settled into the bone a few millimeters. He opted for a sliding genioplasty as he felt that would more reliably give him long-term augmentation.

Sliding Genioplasty with Chin Implant intraop Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral approach was used to access the chin. The chin implant was easily identified and it was nestled nicely into the bone. A horizontal osteotomy cut was made above it from side to side and the bone downfractured. The chin segment was then advanced 12mms and stabilized with a step plate and screws. The chin implant was never moved from its original position during the procedure.

Sliding Genioplasty with Chin Implant result Dr Barry Eppley IndianapolisSliding Genioplasty with Chin Implant 3D CT scan Dr Barry Eppley IndianapolisA sliding genioplasty can be successfully done with an indwelling chin implant. It can be argued that this is a good technique to take advantage of some of the prior procedure (and investment) and gain additional horizontal augmentation. Whatever implant settling has occurred into the bone has already reached its peak and no further inward change would be anticipated.

Case Highlights:

1) An unsuccessful chin implant result can be improved by a sliding genioplasty.

2) It is not always necessary to remove an existing chin implant when doing a sliding genioplasty.

3) A sliding genioplasty can be performed by making the osteotomy cut above the chin implant and moving both forward simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Sliding Genioplasty for Lower Facial Elongation

Tuesday, April 14th, 2015

 

Background: A sliding genioplasty is a well known and historic procedure for changing the shape of the chin. It was originally described in the 1940s but has evolved considerably due to the use of rigid fixation using plates and screws. While once clever osteotomy designs and wire fixation methods were used for stabilization of the bone segments, which limits how much the chin position could be changed, plate and screw fixation now makes virtually any bony chin change possible.

Sliding Genioplasty Indianapolis Dr EppleyFor chin augmentation, the chin implant is often compared to the sliding genioplasty as creating similar effects. But the reality is that this is only partially true and they are only comparable when it comes to pure horizontal movements as seen in the profile view. Vertical and width (narrowing) changes can not be done with an implant. (although newer vertical lengthening chin implants have recently become available)

The real benefits for a sliding genioplasty are when vertical elongation of the chin is needed and when the amount of chin advancement desired exceeds that of which standard implants can achieve. This would be particularly useful in women who can aesthetically tolerate a more narrow chin as it comes both forward and down. The other benefit for a sliding genioplasty in these more substantial chin changes is that it ‘carries’ the soft tissue of the chin pad with it and does not create a devascularizing effect due to maintaining most of the soft tissue attachments (and resultant perfusion) to the bone.

Case Study: This 26 year-old female had a short chin in both horizontal and vertical dimensions. Her lower facial height was disproportionate to the rest of her face. As a result, she appeared to have a full neck/double chin.  She knew she wanted her chin augmented but was just not sure how it should be done.

Sliding Genioplasty result side viewSliding Geniop[lasty result oblique viewUnder general anesthesia, she underwent an intraoral sliding genioplasty. A low horizontal bone cut was done and the chin was advanced 16mm forward and 8mms downward. This was the maximum amount of chin bone movement that could be done while still maintaining some bone contact between the segments. Rigid fixation was achieved by a titanium step plate and screws. The bone gap (step between the upper and lower bone segments was filled with demineralized bone particles. The mentalis muscle was resuspended at closure.

Sliding Genioplasty result front viewThe vertically opening sliding genioplasty can help make the lower face more proportionate by making bringing it forward and down. This will make the jawline have more of a V-shape and will also help get rid of a double chin problem due to lack of bony projection.

Case Highlights:

1) A sliding genioplasty is historically the only chin procedure that can provide both horizontal and vertical elongation of the chin. (custom made implants can now do that also)

2) A vertically opening sliding genioplasty with horizontal advancement will make the chin more narrow as a result of these bony movements.

3) Unless the bony chin movements are extreme, bone grafting of the interpositional gap between the chin segments is not necessary. Even when needed demineralized bone substitutes can be successfully used.

Dr. Barry Eppley

Indianapolis, Indiana

The Step-Off Deformity in a Sliding Genioplasty

Monday, December 1st, 2014

 

The sliding genioplasty is a well known chin reshaping procedure. Unlike its cousin, the chin implant, it has a much greater versatility than simply increasing horizontal projection alone. It can be done to create a multidimensional effect from increasing or shortening vertical height, increasing or dereasing chin width and in some cases even moving the chin backwards for horizontal shortening.

The sliding genioplasty is a pedicled bone flap that maintains muscular attachments from the tongue and neck muscles which keeps the bone alive. While some perceive that it is a free bone graft,. it is not nor would it work if it was. Any bone gap created by the cut bone movement heals because the bone is alive and can make new bone to heal the gap without the need for bone grafting.

Sliding Genioplasty step off front view Dr Barry Eppley IndianapolisThe basis premise of the sliding genioplasty is that it is created by a horizontal full-thickness bone cut through both cortices. The angle of the horizontal bone cut historically controlled how the bone could move since it was wired together and had to maintain some degree of bone contact. But with today’s titanium plate and screw fixation techniques, the angle of the bone cut is less important.

Sliding Genioplasty step off Dr Barry Eppley IndianapolisBut no matter how the bone is cut, the back end of the bone cut goes through the inferior border of the mandible. This usually occurs somewhere behind the level of the mental foramen in the mid body of the mandible. Since the cut chin bone is usually moved forward to some degree, this creates a step-off or inferior edge deformity. The more the chin moves forward, the more than an inverted V step off deformity may be felt. Depending on the patient’s soft tissue thickness, such a step off may even been seen along the edge of the bone.

While step-offs in sliding genioplasties are common, the question is whether they should be managed at the time of the initial surgery. In most cases it is not necessary as the bone remodels over time and their prominence will become less or even completely become non-existent with enough healing time. There is also the issue that their management may potentially cause as many problems as it is intended to solve. Trying to fill the defect at the time of the initial genioplasty with some type of filler (e.g., hydroxyapatite granules) could result in a lump or clump of material that would be just as bothersome as a bone indent may be.

Dr. Barry Eppley

Indianapolis, Indiana

Sliding Genioplasty Modification for Jawline/Lower Facial Reshaping

Sunday, November 9th, 2014

 

In facial reshaping surgery, it is important to appreciate the differences between a Western vs an Asian type face. While a strong jawline is attractive by Western standards, a more narrow lower face that makes an oval or a v-line look is preferred. To achieve this Asian form of mandibular contouring surgery, various forms of sliding genioplasties and lower border mandibular ostectomies have been developed.

The greatest variance amongst the various forms of mandibular contouring has been that of the chin. And the chin also makes the greatest contribution for most patients to the lower facial shape. Reducing the horizontal width of the chin through a central segment bone resection is the most common technique used with a horizontal sliding genioplasty. However this method does not specifically reduce the height of the chin unless a horizontal wedge resection of bone is done at the same time.

In the October 2014 issue of Plastic and Reconstructive Surgery Global Open issue, the article entitled ‘Inverted V-shape Osteotomy with Central Strip Resection: A Simultaneous Narrowing and Vertical Reduction Genioplasty’ was published. In this paper, the authors introduce a simple but very effective method to reduce the chin width and length simultaneously with an inverted V-shaped osteotomy and central segment resection instead of a horizontal osteotomy and central segment resection. Over a three year period, nearly 550 patients (75% female) underwent mandibular contouring surgery of which over 300 were treated with this narrowing and vertical reduction genioplasty technique. No significant complications occurred other than about 1/3 of the patients experienced transient mental nerve numbness which went on to full recovery.

While there are different ways to change the bony shape of the chin, this ingenious method is a clever geometric modification of a traditional linear approach to a sliding genioplasty.The square and long face can be effectively changed into a more slender oval shape as the chin is similarly changed. It also requires a minimal amount of plate and screw fixation and appears very stable for optimal healing.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Maxillomandibular Advancement for Sleep Apnea and Improved Facial Profile

Sunday, November 2nd, 2014

 

Background: Sleep apnea, specifically called OSA or obstructive sleep apnea, can be a limiting condition that adverses affects one’s daytime life. This is evident by excessive daytime drowsiness and problems in concentrating and memory loss. The causes of sleep apnea have been well documented and can involve multiple sites along the nasopharyngeal airway passages for which various types of surgeries can be done.

Obstructive Sleep Apnea Indianapolis Dr Barry EppleyIn severe cases of OSA, the posterior airway can only be improved by moving the base of the tongue  and soft palate forward. This is done by moving the jaws forward, known as maxillomandibular advancement. By moving the upper jaw (maxilla) and lower jaw (mandible) forward, the entire airway is enlarged. This procedure serves as the most effective surgical treatment for obstructive sleep apnea. It is usually performed in a hospital under general anesthesia and takes about four hours to complete. Patients usually remain in the hospital for several days after the surgery and can return to work weeks later when much of the facial swelling has gone down.

Unlike traditional orthognathic surgery, the integrity of one’s bite (occlusal relationship) is not changed. As both jaws come forward the same bite relationship is maintained through the use of small titanium plates and screws. As a result of these plates and screws, the jaws do not need to be wired after surgery.

Maxillomandibular Advancement Surgery Dr Barry Eppley IndianapolisIt is generally recommended that the forward jaw movements be at least 10mms. This creates the maximal change that can be achieved by opening the entire airway space. Its success rate has been documented in numerous studies has being fairly high with a greater than 80% to 90% chance of success for patients with an AHI (apnea hypopnea index) less than 15.

However, moving the jaws forward does have aesthetic consequences. The lower face can  become disproportionate to the lower face as the jaw bones come forward leaving the orbital and forehead skeletal structures behind. This can create an undesireable facial protrusive appearance. Proper presurgical selection and patient education with imaging is important to make patients aware of these potential changes.

Case Study: This 26 year-old female suffered from severe obstructive sleep apnea. Sleep studies showed that her ANI was 8 and she did not want to wear a CPAP device. She had significant daytime tiredness with chronic red eyes. She chronically looked very tired.

Orthognathic Surgery for Obstructive Sleep Apnea Computer Planning Dr Barry Eppley IndianapolisA 3D CT scan was obtained from which virtual surgical planning was done. It was elected to move the maxilla and mandible forward 7mms and combine that with a sliding genioplasty movement of 9mms forward with a slight vertical opening. Cephalometric, model and photographic analysis was also done to see how these changes would look. Her existing bite was already orthodontically corrected into a Class I relationship.

During surgery, a one-piece maxillary advancement was done of 7mms using an interpositional occlusal splint. (computer made from the stone models) Bilateral sagittal split mandibular osteotomies were then done of 7mms placing it into occlusal relationship with the already advanced maxilla using a final occlusal splint. Finally a sliding genioplasty was performed bringing it forward 10mms with 3mms of vertical opening. Al bone segments were secured by titanium plates and screws and no jaw wiring was used after the surgery.

Orthognathic Surgery for Obstructive Sleep Apnea Dr Barry Eppley Indianapolis side viewOrthognathic Surgerry for Obstructive Sleep Apnea Dr Barry Eppley Indianapolis front viewHer after surgery results (a one month) showed a dramatic positive change in her facial appearance with a better facial profile and facial length. This is not surprising given her significant short mandible, chin and neck. Her sleep apnea had also improved with complete resolution of her daytime sleepiness. The tired red eye look was replaced by a more awake white-eyed appearance.

Orthognathic Surgery for Obstructive Sleep Apnea Dr Barry Eppley IndianapolisUndesireable facial changes can occur in some patients after maxillomandibular advancement for sleep apnea. Upper lip protrusion, an open nasolabial angle and bimaxillary protrusion can result from this surgery for certain facial types. Those patients who have a preoperative dolichofacial (long)) or brachyfacial (short) facial types will usually have improved aesthetic outcomes from maxillomandibular advancement for OSA.

Case Highlights:

1) Bimaxillary advancement (upper and lower jaws) can be a very effective treatment for severe obstructive sleep apnea.

2) While moving the jaws forward as much as possible gets the best chance for sleep apnea improvement, it can also cause a facial disproportion and an undesireable change in one’s appearance.

3) Moderating the amount of jaw movement to what aesthetically improves the face as well is an important consideration in treatment planning.

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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