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Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

August 2nd, 2014

Forensic Use Of Breast Implant Identification Numbers

 

The implantation of medical devices is extensive and varied and crosses all surgical specialties. Plastic surgery is no exception with the use of a wide array of implants from the face to the legs. The most recognized and largest medical device that is implanted in plastic surgery is that of the the breast implant. Having now been around for over fifty years, numerous types of breast implant manufacturers have come and gone. Today there are three FDA-approved U.S. manufacturers with dozens of different types of saline and silicone breast implants.

Every breast implant that is manufactured today as its own serial and identification number. When a patient is implanted, a sticker with these numbers is attached to a patient record which is faxed to the manufacturer, a copy is maintained in the plastic surgeon’s records and a plastic card is given to the patient. In essence, breast implants are very trackeable for the most part.

This brings to light a recent story out of Indiana. A serial number from a pair of breast implants served as a means of identification for a murder victim. A flight attendant working out of Chicago was found dead in the trunk of her car in northern Indiana. The coroner on the case knew that breast implants have serial numbers because of his spouse’s experience with breast reconstruction from cancer. With some research he located the victim’s breast implant manufacturer. The implants were then traced to the plastic surgeon who performed her breast augmentation surgery in northern Indiana. These implant records combined with photographs and dental records confirmed the victim’s identity.

The most common use of serial numbers in breast implants is when the patient needs to invoke their warranty due to a failed device for replacement surgery. While all patients hope that they never have to use their breast ID numbers in this fashion, many will. Forensic patient identification would be another potential use of breast serial numbers that fortunately few patients will ever have to use.

Dr. Barry Eppley

Indianapolis, Indiana

July 31st, 2014

Case Study: Custom Male Forehead Implant

 

Background: The male forehead is uniquely different from that of females. It has more prominent brow bones, a well defined brow break and a forehead that has no more than 10 to 20 degree angulation backward into the frontal hairline superiorly. This is quite different from a female’s forehead which ideally has little to no brow prominence and a more vertical and convex forehead shape.

Forehead augmentation is less common in men than females. Usually most men who present for aesthetic forehead surgery have brow bones that are too prominent and they want them reduced. But occasionally a man may want a more masculine forehead shape that has the aforementioned male forehead features as well as some increased width.

Traditionally, reshaping a forehead using an augmentation method has been done using bone cements. Through a full coronal incision, the bone cement is mixed, applied and shaped through wide open exposure. This allows for the best shape creation and to eliminate the risk of any edge or transitional material concerns into the surrounding tissues. But such hand shaping must rely on the surgeon’s skill and experience at creating the desired forehead shape.

Custom Forehead Implant Design Dr Barry Eppley IndianapolisCase Study: This 28 year-old male wanted a masculine forehead shape. He desired the classic male forehead features with more brow bone protrusion, a brow bone break and less vertical angulation upward. His present forehead had minimal brow bones and a very retroclined forehead slope. Using a 3D CT scan, a one-piece forehead implant was designed with the requisite features.

Custom Forehead Implant result side view Dr Barry Eppley IndianapolisUnder general anesthesia, a limited coronal scalp incision was made well behind his existing hairline with no shaving of hair. Subperiosteal elevation was done down to the brow ridges with release of the periosteum. Dissection was carried out onto the deep temporal fascia. The custom implant was inserted, seated and secured into position along its upper edge with three small self-drilling titanium screws. The scalp incision was closed in layers with dissolvable sutures.

Custom Forehead Implant result oblique view Dr Barry Eppley IndianapolisA custom forehead implant is an ideal method to get the best fit and shape for an augmentation effect. It also makes the operation take less time which nearly offsets the increased cost of making the custom implant. A somewhat smaller scalp incision can also be used. In addition with a more assured aesthetic outcome the risk of revisional surgery is also lessened.

The use of custom implants for the craniofacial area continues to grow and expand and its use in the forehead represents another example of its growing role in aesthetic facial surgery.

Case Highlights:

1) Forehead augmentation in men is designed to increase the prominence of the brows and decrease the posterior angulation of the forehead.

2) Forehead augmentation can be done using either intraoperatively applied bone cement or preformed custom implants.

3) Forehead augmentation with custom implants made from the patient’s 3D CT scan provides an optimal fit to the bone and the best smoothness and symmetry in the implant’s shape.

Dr. Barry Eppley

Indianapolis, Indiana

July 27th, 2014

Facial Shape and Intelligence in Men

 

The human face is anatomically complex and how it is interpreted by others even more so. A face and its expressions tell others a lot from impressions of personality to attractiveness. It has been reported by some researchers, albeit controversial, that the more attractive one is the more intelligent they are believed to be. This is certainly not true as we all know but that is just one of the positive attributes that has been assigned to facial attractiveness.

Although a number of research studies have looked at the relationship between perceived intelligence and facial attractiveness, what specific facial features create this impression has not been studied. The ability to assess intelligence in other people and be accurate in that assessment has obvious important ramifications in many aspects of lift.

Facial Shapes and Intelligence in MenIn the online journal PLoS One issue 9 2014, a study entitled ‘Perceived Intelligence Is Associated With Measured Intelligence in Men But Not Women’. In this paper, the aim was to determine which facial shape traits create the perception of intelligence as well as those that correlate with actual intelligence. The study used static facial photographs of forty men and forty women and looked at the relationship between measures IQ, perceived IQ and facial shape.

The study found that both men and women were able to accurately evaluate the actual  intelligence of men by viewing facial photographs. No such relationship was found between perceived intelligence and IQ in women. Faces that were perceived as highly intelligent are longer vertically with a broader distance between the eyes, a larger nose, a slight upturn to the corners of the mouth, and a sharper and less rounded chin. By contrast, the perception of lower intelligence was associated with broader, more rounded faces with eyes closer to each other, a shorter nose, declining corners of the mouth, and a rounded and larger chin.

These study results suggest that people can accurately gauge the real intelligence of men, but not women, by viewing their faces in photographs. It appears that certain facial shapes in men create an intelligence perception. This may be one of the underlying motivations for men seeking procedures that enhance their nose and jawline which help to create this more desired facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

July 27th, 2014

Technical Strategies In Plastic Surgery – Laser Assisted Otoplasty

 

Mustarde Sutures in OtoplastyThe correction of prominent ears by standard otoplasty techniques has been around for decades. Using horizontal sutures of various materials, known as Mustarde sutures, the antihelix is created or made more prominent to pull the helix of the ear back into a more asesthetically acceptable position. While there are other aspects of the ear (concha, earlobe and skin on the back of the ear) that may need simultaneous reshaping, the placement of sutures into the cartilages to reshape it is the foundational maneuver in otoplasty surgery.

otoplasty markingsWhere to place these horizontal mattress sutures in the ear cartilage is the hardest part of the procedure. Accurate suture placement is key to getting the right ear cartilage shape. The traditional technique is to mark the ear prior to making the postauricular incision by using a needle and dye in a percutaneous fashion at the exact points that the sutures should bite into the cartilage. This is usually done using twelve cartilages marks so that three horizontal mattress sutures could be placed.

Laser Assisted Otoplasty Dr Barry Eppley IndianapolisSome plastic surgeons, including myself, do not mark the cartilage prior but instead use a free hand technique. In this method it is estimated where the sutures should be placed once the skin on the back of ear has been removed and the cartilages exposed. This is a trial method of suture placement which often can takes multiple tries to get all the sutures in the right place for the desired ear shape. It is effective but can sometimes be tedious to get just the right placement.

Laser Pointer in Otoplasty Dr Barry Eppley IndianapolisA non-needle method to use for marking where the sutures should be placed can be done using a laser pointer. With the ear cartilage exposed and folded forward, a laser pointer is used to point to the correct skin position. This can be done by someone holding the small hand-held laser device pointer and be told where it should be pointed or can be done with the surgeon holding it themselves in a sterile glove or wrapping. The penetrating beam of the laser pointer can be seen on the exposed cartilage on the opposite side from where it entered the skin. Hence, the term ‘laser-assisted otoplasty’. It serves the same purpose as the needle and dye but without piercing the skin with a needle.

Dr. Barry Eppley

Indianapolis, Indiana

July 26th, 2014

Correction Of Cheek Implant Asymmetry

 

Cheek Implants Indianapolis Dr Barry Eppley IndianapolisWhile cheek augmentation can be done by synthetic injectable fillers or fat injections, the only assured permanent method is through the use of preformed implants. Cheek implants come in a variety of styles and sizes and it is critical to make these implant choices thoughtfully to get the desired midface result. The most common aesthetic cheek implant complication, however, is that of asymmetry.

Cheek implants are the second most commonly performed facial implant used behind those used for the chin. But unlike chin implants, cheek augmentation requires the use of two implants that must be placed with their symmetry in mind. But cheek implantation sites can be difficult to see simultaneously and their symmetry is usually assessed by external evaluation of how the cheeks look. But swelling and other tissue distortions can mar the accuracy of this comparative assessment. This external view is complemented by also assessing how the implants rest on the bone between the two sides.

Cheek Implant Shift and Asymmetry Dr Barry Eppley IndianapolisBut despite the best placement efforts, cheek implant asymmetry can occur. This could be due to initial asymmetric implant placement or a migration/shift of the implant afterwards. Due to the size of the implant pocket initially, unsecured cheek implants can shift move right after surgery. (early displacement) It is very rare to have a cheek implant change position months or years later (late displacement) although it can happen. Why a cheek implant would have such a delayed shift in position long after the enveloping capsule (scar) around it has been created and healed could be infection or a reactive seroma formation. Surgery performed near the implant can also cause an implant  reaction and subsequent shift. (picture shows a CT scan with cheek implants at two different positions and a reactive fluid collection around the left cheek implant as it moves its way towards the mouth incision)

Cheek Implant Repositioning Dr Barry Eppley IndianapolisCheek implant reposition surgery can be performed but is rarely as simple as just ‘moving the implant around’. Because scar tissue forms around all synthetic materials, repositioning of implants usually requires some form of capsulectomy/capsulotomy. (releasing or excising portions of the existing implant’s pocket) In addition, it is critically important to secure the cheek implant into the new position and this is most reliably done by screw fixation with self-tapping titanium 1.5mm microscrews. A layered closure over the implant consisting of muscle and mucosa is also important to keep as much soft tissue between the intraoral cavity and the implant pocket.

Because of the path of cheek implant insertion, asymmetry or migration of the implant is usually downward towards the location of the incision. This occurs also because the cheek bone is sloped downward and the maxillary bone underneath it is concave, making movement in that direction easy. Thus , most cheek implant repositioning is moving the implant back up over the bone.

Dr. Barry Eppley

Indianapolis, Indiana

July 25th, 2014

Nasal Tip Rotation and Projection in Rhinoplasty

 

Rhinoplasty Tip Rotation and Projection in Rhinoplasty Dr Barry Eppley IndianapolisWhile there are many changes to the nose that can be done in rhinoplasty, one of the most significant and sought after is tip rotation. While tip position is very relevant to both genders, elevating and narrowing a low hanging tip is a particular focus for many female rhinoplasty patients. While it is well known that the nasolabial angle is more open and the tip is higher in women, there are no universally accepted methods to define the ideal nasal tip rotation and projection in women.

In the June issue of the JAMA Facial Plastic Surgery Journal, an article was published entitled ‘Population-Based Assessment of Currently Proposed Ideals of Nasal Tip Projection and Rotation in Young Women’. In this study, side view pictures were taken of young women between 18 and 25 years of age. Each picture was digitally assessed and modified with nasolabial angles of 96 degrees to 116 degrees at 5 degree increments. The pictures were then assessed for attractiveness by a variety of social groups. The most preferred nasolabial angle was found to be 106 degrees with a Crumley 1 tip projection. This angle was particularly preferred in faces that were considered to have above average attractiveness.

The nasolabial angle along with nasal tip projection are considered two of the most important side profile features of the nose. The nasolabial angle is straightforward to determine. When it is open too far, the nose can look short with too much nostril show. When it is too closed, the nose looks long and droops down

Nasal tip projection is somewhat less clear and has been traditionally defined as the distance along a perpendicular line from the vertical facial plane to the most anterior projecting point of the nasal tip. When there is too much tip projection, the nose looks long and out of balance with the rest of the face.

But there is an intimate relationship between nasal tip projection and rotation. A nose that is too long, even with a desirable nasolabial angle, will still not look good. Conversely, a short nose with too much or too little of a nasolabial angle will look even shorter.

While these nasal measurements along with many others can not always be replicated with certainty during rhinoplasty surgery, they serve as good guidelines to follow.

Dr. Barry Eppley

Indianapolis, Indiana

July 24th, 2014

Case Study: Liposuction of the Large Male Neck

 

Background: The shape of the neck is one of the most important aesthetic facial areas. Having a shapely neck allows the chin and the jawline to be more clearly seen which not only creates improved facial definition but creates a more youthful look. This is evidenced in patients who undergo weight loss and those who have facelift/necklift surgery.

The anatomy of the neck is fairly simple and has three distinct structures that are interdependent. There is the overlying skin, the underlying platysma muscle and the intervening skin.There are also structures underneath the platysma muscle (fat, submandibuar glands) but there are not as easily accessed or changed. How much loose skin and fat one has plays a major role in the shape of one’s neck.

Male Bull Frog Neck Dr Barry Eppley Indiana IndianapolisIn a large or ‘bull neck’ the contribution of the fat can be considerable. This is most frequently seen in men and women who often carry excess weight. This is no surprise given what percent of fat makes up the neck. The heavier in weight one is, the bigger the neck usually is. Weight loss can help reduce the size of the neck but that alone often is not completely successful.

Case Study: This 45 year-old male wanted to improve his neck. He was a large man but carried his weight well due to his height. But his large neck was disproportionate to how the rest of his body appeared. In reviewing the options for neck contouring (liposuction, liposuction with submentoplasty and a necklift/lower facelift), he opted for liposuction alone without any tissue excision. He did so with the understanding that the neck contour change would be the most limited and would only be about a 1/3 of that of a necklift.

Large Neck Liposuction result side viewUnder general anesthesia, the neck was infiltrated with a lidocaine and epinephrine solution. With small cannulas from puncture skin entrance sites under the chin and behind the earlobes, the entire neck was aspirated of fat from the supraplastysmal/subcutaneous layer. A total of 38cc of fat aspirated was obtained. A compressive neck dressing was applied.

Large Neck Liposuction result oblique viewIt usually takes at least six weeks after neck liposuction until most of the swelling, hardness and lumpiness resolves. It is common and to be expected due to gravity that prolonged fullness and stiffness of the tissues will be persistent in the lower half of the neck for awhile. The final result of any neck liposuction procedure should not be judged until three months after the procedure. The assurance of a final result is when the neck feels soft, the numbness of the skin is gone and it longer longer feels sore or hurts when squeezed.

The success and limits of neck liposuction depends on what the skin will do. How much will it contract and shrink up? That will depend on how much extra skin exists and how much elasticity it has. Generally male neck skin has a better ability to contract than females due to thicker skin and more innate elastic fibers. But there is a limit to skin contraction and almost all full large neck liposuction results will not be a cut and sharp cervicomental neck angle. There will be improvement but more significant results require skin management as well.

Case Highlights:

1) Large full necks are an aesthetic challenge because of the amount of excess skin that exists.

2) In younger patients with thicker skin that may have some remaining elasticity, liposuction alone can have a positive effect without risk of loose residual skin.

3) The results of neck liposuction can always be followed by a secondary necklift for further improvement.

Dr. Barry Eppley

Indianapolis, Indiana

July 20th, 2014

Arnica in Recovery From Plastic Surgery – Is It Effective?

 

Arnica is a well known and recognized homeopathic supplement in plastic surgery. It is touted as an anti-bruise and anti-inflammatory treatment measure that is widely prescribed after many procedures from injectable fillers to facelifts. While it is widely used, the interesting question is whether it is really effective and what is the evidence that it works.

Arnica FlowerArnica is an orange-yellow flower that has its origin from Europe where it once grew over large areas. It is a genus with dozens of perennial herbaceous species belonging to the sunflower family Asteraceae. Several species within this genus contain helenalin (e.g., Arnica Montana) which is found in the leaves and stems of the flower. This is the agent that is believed to be responsible for any anti-inflammatory benefits.

Historically there are few studies that have shown that Arnica was more effective than a placebo for any of its touted benefits. More recent animal studies have shown increased levels of anti-inflammatory cytokine interleukin (IL-10) and decreased levels of pro-inflammatory protein tumor necrosis factor. (TNF) Both effects can have clinical effects of reduced swelling and inflammation. A clinical study of carpal tunnel surgery showed less pain at two weeks when oral and topical Arnica was used. In a clinical study of big toe surgery, Arnica was found to be equally effective at reducing wound irritation (less effective at pain reduction) but less costly and better tolerated than Diclofenac. A clinical study to evaluate bruising in facelift surgery did show a significant lessening of the amount of bruising with Arnica Montana.

The clinical evidence that Arnica has a significant anti-inflammatory effect is not strong. There is only one clinical study that shows it has an anti-bruising.  (despite the fact that it continues to be highly touted as such) There are a surprisingly limited number of studies in the plastic surgery literature that have been done let alone show it has beneficial recovery effects. But Arnica continues to be used in plastic surgery largely because there is no harm in doing so and it is very inexpensive. There is likely something to the homeopathic effect of a ‘natural remedy’ that also propagates its continued use.

Arnica Montana in Plastic Surgery Dr Barry Eppley IndianapolisOne of the problems with the use of Arnica is that its preparations have wide variability. Unlike a prescription drug, how Arnica tablets and creams are prepared is without significant manufacturing standards. Then there is the X and C potency or dose letter attached with a number. This adds to the confusion. An X preparation (decimal system) is, for example, where one part of the medicinal substance is mixed with nine parts of the vehicle. (1+ 9 = 10) In this system the X always follows the number. In a C preparation (Centesimal system), one part of the medicinal substance is mixed with ninety parts of the vehicle. Like the X system, the C always follows the number. It can be seen, therefore, that 10X and 10C Arnica preparations for example are not comparable in potency. The purpose of the letters X and C is to indicate how they are prepared and as no indication as to its potential effectiveness like typical milligram dosages of drugs are.

Because of the wide variability in how Arnica is prepared and the difficulty in studying the clinical effects of swelling, pain and bruising, demonstrating that Arnica actually has any positive benefits on surgical recovery is difficult.  Its continued use will be based on limited clinical information of its effectiveness and more on whatever placebo effects it may provide.

Dr. Barry Eppley

Indianapolis, Indiana

July 20th, 2014

Technical Strategies in Plastic Surgery – Fat Grafting in Migraine Surgery

 

Contemporary migraine surgery for the treatment of perpheral triggers involves decompression of the involved nerves. The most common involved nerves include the supraorbital, supratrochlear and the greater and lesser occipital nerves. (the zygomaticotemporal and auriculotemporal nerves are avulsed so they are excluded)  The success of nerve decompression depends on adequate release of the enveloping muscle and fascia so any pinching effect on the nerve is eliminated.

But decompressive migraine surgery does not always produce sustained relief and one of the reasons is recurrent compression due to scar formation. Despite being relieved of constructive muscle fibers, the surrounding tissues do have to heal and the space left behind can be replaced with scar tissue. Such scar tissue formation naturally contracts as it heals, thus potentially replicating the initial nerve compression problem.

Greater Occipital Nerve Decompression Dr Barry Eppley IndianapolisGreater Occipital Nerve Decompression with Fat Graft Dr Barry EppleyOne simple strategy to prevent recurrent nerve compression in migraine surgery is the use of fat grafts. Placing a fat graft over or around the released nerve can have several beneficial effects. Its obvious benefit is that it fills the open space around the nerve from the release and provides a quickly revascularized soft tissue buffer from the surrounding tissues. The other potential benefit is less obvious and unproven but theoretically possible.

Fat tissue is seen today as an active and secreting organ that produces a variety of special proteins. One of these are neurotrophic factors such as nerve growth factor and brain-derived neurotrophic factor. Such factors are known to have a role in stimulating repair of peripheral nerves as well as a regulator of immune and inflammatory responses. Placing a fat graft against a nerve that has been compressed and inflamed may have a healing and reparative effect.

The harvest of a small fat graft is quick and easy and its placement onto the released nerve is similarly so. There is no morbidity in doing so and fat graft placement around the nerve can be done either in an open wound or in an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

July 19th, 2014

Case Study: Temporal Implants in Severe Facial Lipoatrophy

 

Background: Facial lipoatrophy is the loss of facial fat which has various causes. Genetics, aging, weight loss and side effects of medications can all create variable degrees of facial fat loss. While fat exists throughout the face in the subcutaneous plane and around the eyes, the largest concentrated fat depot is in the buccal space. It is this fat area that is mosts severely affected in all degrees of facial lipoatrophy.

Buccal fat Pad Anatomy Dr Barry Eppley IndianapolisKnown as the buccal or Buchat’s fat pad, it is located deep in the face between various facial and masticatory muscles underneath the cheek bone. While it is called the buccal pad because of its primary location, it has numerous extensions or fingers into the pterygoid and temporal regions. Thus when loss of part or even all of the buccal fat pad occurs, temporal hollowing ensues along with submalar indentation.

The treatment of temporal hollowing is most commonly done by a variety of injectable filler materials. Hyaluronic acid-based and particulated fillers are office treatment methods while fat injections is more of a surgical approach. While these injection treatments for temporal hollowing can be effective, they are rarely permanent, may require multiple treatments, and are prone to irregularities and asymmetry.

Case Study: This 45 year-old male requested treatment for generalized facial lipoatrophy. One of his areas of concern was his very deep temporal hollows which were very concave and whose depth was well below the level of the zygomatic arch. This gave him a very skeletonized appearance across the bitemporal region.

Temple Implants in Facial Lipoatrophy result front view Dr Barry Eppley IndianapolisUnder general anesthesia (as he was undergoing various other facial procedures), small vertical incisions were made in the temporal hairline above the ears. After locating and incising the deep temporal fascial plane, blunt disection developed a pocket to the laterial orbital rim and along the superior edge of the zygomatic arch. Small soft silicone temporal shell implants were easily slide into the subfascial pocket, creating an instant temporal augmentation effect. The incisions were closed with dissolveable sutures.

Temples Implants in Facial Lipoatrophy result oblique view Dr Barry Eppley IndianapolisAugmenting temporal hollows with a preformed implant creates a muscular augmentation effect unlike most facial implants whose aim is to create a bone augmentation effect. It is the soft tissue volume of the temporal region that is lost in facial lipoatrophy below the level of the subcutaneous fat beneath the skin. Thus it seems most logical to treatment the exact location of the tissue loss which is the temporal fat pocket beneath the temporalis fascia.

Placement of an implant in the subfascial temporal plane is a very easy dissection and pocket to create. This pocket location for the temporal implant requite no form of fixation as it can not migrate below the level of the zygomatic arch due to the narrow space behind the arch and the blocking effect of the coronoid process of the mandible below it.

Temporal implant augmentation offers a simple surgical solution that is both permanent, has yet to reveal any significant medical risks, and involves minimal discomfort and swelling. It has the fastest recovery of any of the facial implant procedures.

Case Highlights:

1) Temporal hollowing is a major manifestation of significant forms of facial lipoatrophy.

2) A soft silicone temporal implant is a new method to permanently correct temporal hollowing by muscle augmentation.

3) Temple implant augmentation is a simple surgery that has virtually no significant recovery or swelling associated with it.

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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