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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.

December 22nd, 2014

Plastic Surgery Case Study – Male Forehead Augmentation

 

Forehead Shapes Dr Barry Eppley IndianapolisBackground: The forehead represents one third of the face and had a valuable role to play in facial aesthetics. Besides the length and width of the forehead, its other major aesthetic feature is its slope. (as most easily appreciated in the side view) This forehead feature is well known to be gender specific. Women have more vertical inclined forehead (with convexity) and a smooth transition into the brow bones. Conversely men have a more inclined forehead with defined brow bones and a definitive break between the brow bones and the forehead.

Most men that desire forehead changes have issues with either the prominence of the brow bones or shape of the forehead above it. While both may be at fault, isolated forehead concerns are usually because of lack of projection. The forehead slopes back too far. The more retroclined the forehead slope is, the more unaesthetic it becomes as it creates more of a ‘neanderthal’ appearance by making the brow bones bigger.

Male forehead augmentation can be successfully done through two methods of bone augmentation. Options include the application of a bone cement (like PMMA) or the preoperative fabrication of a custom designed silicone implant. Each method has its own distinct advantages and disadvantages but both can be very effective. PMMA cement application requires an artistic sense to apply it evenly without over correction or palpable temporal edges.

Case Study: This 35 year-old male wanted to improve the shape of his forehead as he felt it had too much of a backward slope to it. It had a near 55 degree angulation and he wanted it almost vertical in a profile view.

Male Forehead Augmentation result side viewUnder general anesthesia, a limited coronal scalp incision was made without shaving any hair. A limited coronal incision means that it does not go all the way down to the ears but the incision stays 3 to 4 cms above it one each side. The forehead was exposed in the subperiosteal plane down to the brows inferiorly and to the temporal line at the sides. Using 60 grams of PMMA cement mixed with antibiotic powder, it was applied as a putty and shaped using the forehead/scalp flap to create the desired angulation and make it snooth. Once set the temporal and back edges were smoothed. The scalp incision was closed with dissolveable sutures with no use of a drain.

Male Forehead Augmentation result oblique viewRecovery from the forehead augmentation was fairly quick with no bruising or significant eye swelling. The improvement in the slope of the forehead was noted immediately with full appreciation of the final effect by six weeks after surgery. Scalp numbness behind the incision line took over three months to return to normal. The final forehead contour was smooth with the exception of a small indentation behind the hairline on the left temporal side which was not a major concern to the patient.

The historic method of forehead augmentation with PMMA bone cement is still an effective treatment approach. Its biggest drawback is that it must be intraoperatively shaped and this introduces the variable of irregularities or shape issues. Considerable experience is needed in working with bone cements in their putty phase to master their handling and shaping.

Case Highlights:

1) Forehead augmentation in men is usually done to correct a severely backward sloping forehead which accentuates the size of the brow bones.

2) One method of forehead augmentation is the application of bone cement through an open scalp incision.

3) The shape of a male forehead augmentation is to change the slope of the forehead but to still preserve a brow bone break.

Dr. Barry Eppley

Indianapolis, Indiana

December 21st, 2014

Technical Strategies in Plastic Surgery – Sagittal Ridge Skull Reduction

 

One of the most common of all aesthetic raised skull deformities is that of the sagittal ridge. As a result of the fusion of the midline sagittal suture, bone thickening can occur between the original anterior and posterior fontanelles. In its fullest expression such sagittal suture fusion becomes a craniosynostosis. But there are numerous smaller or incomplete versions of craniosynostosis where only a raised ridge of bone occurs down the middle of the skull without causing a lengthening of the skull from front to back or any significant transverse narrowing.

Sagittal Ridge Skull Deformity Dr Barry Eppley IndianapolisThe sagittal ridge or crest creates a prominence that is particularly visible in men with short hair or who shave their head. It makes the top of the head appear as an inverted V as opposed to a more smooth convex shape. Only in animals is the presence of a sagittal ridge normal which is due to the attachment of the strong masseter muscles. The tenporalis muscle in humans is attached far more to the sides of the skull which allows it to have a more recognizable smooth convex shape.

Sagittal Ridge Skull Deformity burring reduction Dr Barry Eppley IndianapolisThe reduction of the sagittal ridge can be effectively done through a burring technique. One key is to keep as small an incision as possible which is located at the back portion of the ridge. While the back portion of the ridge is fairly easy to reduce, the portion of the crest that extends forward is more challenging. The second key is to have long narrow retractors which allows a handpiece and shaping burrs to be  inserted to complete the reduction. Any residual high bony areas located way far forward can be reduced with large diamond rasps.

An important question to answer before this type of skull reshaping surgery is how thick is the sagittal ridge and how much can it be reduced. This can be quantitatively determined before surgery with a 3D CT scan where the bone thickness can be measured. When burring down the ridge it is common, particularly in the back, to encounter large bone bleeders and these are effectively obliterated with bone wax. When the color of the midline bone starts to become a faint blue in color, it is time to stop as the inner cortex is getting thin. Usually up to 7mms of crestal bone can be reduced.

Dr. Barry Eppley

Indianapolis, Indiana

December 16th, 2014

Plastic Surgery Case Study: Submental Rebound Relaxation After Facelift

 

Background: A facelift is one of the most well known but also misunderstood of the anti-aging facial surgical procedures. Besides the frequent misinterpretation of what a facelift really is, there is also the confusion added to it by the marketing of many ‘franchise’ forms of facelifts which promise big changes with limited recovery. Numerous other minimally invasive to non-surgical types of lifts created by fillers and energy-based devices add to the mix of ‘facelift’ options.

Facelift Vectors Dr Barry Eppley IndianapolisBut moving beyond what constitutes a facelift are other important concepts such as the results and its short and long-term effects. Patients often ask how long a facelift lasts with  an understanding that it is not a permanent result. Like the onward march of time, aging will continue and the results of most facelifts will eventually be lost. (perhaps not completely but some of its effects will surely dissipate)

The most noticeable change will be in the neck and it should be divided into a short-term and a long-term change. The long-term change is obvious and refers to when one may return to what they looked like before the surgery. Estimates vary and no one number can factor in all the patient variables but the time frame of 8 to 12 years is often quoted. But a potential short-term change is often overlooked…a phenomenon known as rebound relaxation.

Case Study: This 65 year-old female wanted to improve her sagging neck and jowls. While the upper portion of her face had similar aging changes, these were not of concern to her. She stated that she did not look this way until about ten years ago when it started.

Necklift result Dr Barry Eppley Indianapolis side viewUnder general anesthesia, a full lower facelift was performed including neck defatting, platysmal plication and SMAS imbrication. Enough skin was mobilized back up over the ears that the entire ear had to be cut out from the mobilized skin redraping during closure.

Necklift result Dr Barry Eppley Indianapolis oblique viewNecklift result Dr Barry Eppley Indianapolis front viewAfter a full recovery, she had a great result with a fairly sharp cervicomental angle and no evident loose neck skin. When seen at six months after the procedure, she still had a very significant change but there had developed a small amount of loose skin or banding in the submental region under the chin. This was not an aesthetic concern to her not did she want anything done about it. She felt she had aged an ‘additional six months’ since the surgery.

Almost no matter how ‘tight’a facelift may be done, the ability of the result to hold is partially dependent on the elasticity of the skin. To no surprise, older aged skin has lost a lot of elasticity and will exhibit some relapse or skin relaxation afterward. This is usually seen in the submental region which is most distant from the point of pull of a facelift.(ears) These submental changes are not aging but a secondary skin relaxation phenomenon which is not usually seen until three to six months after surgery. Sometimes it does not become evident until about one year after the procedure. A submentoplasty procedure can be done to ‘touch up’ the facelift result and attacks this problem through direct skin excision.

Case Highlights:

1) A lower facelift works by a combination of removal and repositioning with the skin part being the most visible.

2) The vast majority of facelift patients want a natural looking result that is not oevrpulled or has a ‘windswept’ look.

3) Every facelift, no matter how much tissue removed, will undergo some degree of submental relaxation in the first six months after surgery. This should not be construed as recurrent aging or failure of the facelift. A secondary submentoplasty may be needed for optimal neck correction.

Dr. Barry Eppley

Indianapolis, Indiana

December 15th, 2014

Technical Strategies in Plastic Surgery- A Simplified Cheek Dimpleplasty Method

 

The cheek dimple is an anatomic anomaly that is often inherited. They can occur on just one side of the face but more commonly are bilateral. They can be present only when one smiles or is always present and just gets deeper when one smiles. Cadaveric studies have shown that it is created by a defect in the zygomaticus muscle and represents, in essence, a tissue defect/deficiency between the skin and the underlying muscosa.

This anatomic knowledge is important when trying to create a surgical technique to create  cheek dimples. (cheek dimpleplasty)  Few surgical techniques have been published and one consistent reliable method has not been described to my knowledge. I have tried numerous cheek dimple creation methods and it is not as simple to achieve a more natural  looking dimple as it may seem.

Cheek Dimpleplasty Technique mucosal punch incision Dr Barry Eppley IndianapolisMaking a cheek dimple is really about creating a dermal adhesion to the underlying muscle. The first step is to mark where the patients wants the cheek dimple and numb the area with local anesthesia. A small incision is made inside the mouth using a dermal punch to remove the mucosa passing it over a needle introduced from the outside skin mark.

Cheek Dimpleplasty Technique percutaneous suturing Dr Barry Eppley IndianapolisSharp scissors are then used to make a pathway from the oral mucosa through the muscle and out to the underside of the skin. A plain gut dissolving suture on a straight needle is passed from inside the mouth and out through the skin. The needle is turned around and passed back inside the mouth moving it over from the skin exit hole by about a millimeter.

Cheek Dimp[eplasty Technique suture tying Dr Barry Eppley IndianapolisBecause it is a dissolveable suture, I pass two separate sutures and tie each one down individually with the knots on the inside of the mouth. When tying the sutures the cheek dimple is created and it is always best to tight them fairly tight and ‘overcorrect’ the depth of the dimple. The unpredictable part is how well the dermis will adhere down to the muscle. But with two sutures per dimple, the odds are increased that some adhesion (and dimpling) will occur. After the sutures are tied down, a single resorbable suture is used to close the small circular cheek mucosal incision.

Dr. Barry Eppley

Indianapolis, Indiana

December 15th, 2014

Silicone Breast Implants Under 22 Years Of Age

 

Since silicone implants were re-introduced eight years ago in 2006, they have gradually returned to their dominance over saline breast implants. With a more natural feel, lack of a deflation risk and being longer lasting, they have numerous advantages over saline-filled devices. But despite their commercial availability they are not available to all women who desire breast augmentation. By the manufacturer’s guidelines they are restricted to women who are at least 22 years or older.

Silicone Breast Implants Indianapolis Dr Barry Eppley IndianapolisThis silicone breast implant restriction runs into a frequently posed question by younger patients…why can I not have these type of breast implants if I am younger than 22 years old? What could possibly be the difference between the breasts of a 20 year old vs a 22 year old? Why would saline implant be allowed but not silicone implants.

This is both a frequent and understandable question as human anatomy clearly shows that they are no physical differences. This is not a biologic issue but a regulatory one. It is presumed by many surgeons that the FDA mades this stipulation to the manufacturers because patients under 22 years of age were never included in the clinical trials that served as the basis for their approval. However the clinical data showed that such young females were indeed part of the silicone implant study group for all manufacturers. So the decision by the FDA to restrict silicone implants by age seems a bit perplexing but nonetheless a stated regulation.

While this age restriction exists, some plastic surgeons do provide silicone breast implants to women under 22 years old. They take the position that this merely represents off-label use and within the province of the physician’s discretion and judgment. Conversely, many other plastic surgeons will not place silicone implants in these younger women as a strict adherence to the regulatory stipulations. Which one is right?

The answer is simply unknown. It is ultimately up to the plastic surgeon and what they feel in is the best interest of their patients and what their liability exposure is. At the least, patients under 22 years of age need to know of the manufacturer’s stated age restrictions and whether placing them at this age may affect the manufacturer’s warranties of the implants. (lifelong implant replacements) It is not clear what position the manufacturer’s take on this issue.

Dr. Barry Eppley

Indianapolis, Indiana

December 14th, 2014

Plastic Surgery Case Study: Female Jaw Enhancement with Vertical Lengthening Angle Implants

 

Background: The jawline is an important facial feature of both men and women. Occupying the entire lower third of the face, it has both a large surface area as well as serves as a distinct transition between the face and the neck. While a well defined and ‘strong’ jawline has been traditionally assigned as a masculine feature, it has become increasing apparent in contemporary culture that women can be considered attractive with a well defined jawline as well.

Angelina Jolie Square Jaw Angle Dr Barry Eppley IndianapolisFemale Strong Jawline Dr Barry Eppley IndianapolisCelebrities such as Angelina Jolie, amongst others, have brought the spotlight onto the beauty of the a‘strong’ female jawline. Careful inspection of these examples shows that what they all have is sharp and well defined jaw angles. It is not so much the width of the jaw angles (although some do have that as well) but a jaw angle that sits well below the earlobe and has a more obtuse angle to it.

Obtuse Jaw Angle in Women Dr Barry Eppley IndianapolisThe angle in the back of the jaw is reflected in how the vertical ramus and the horizontal body of the mandible forms during growth. The length of the jaw angle is created by the development of the vertical ramus of the mandible from the downward growth created by the condyle. Shorter jaws and chin have a high angle point and a more steep mandibular plane angle. The longer the development of the vertical ramus, the lower the jaw angle will be with a less steep mandibular plane angle. A pleasing obtuse jaw angle is usually around 120 degrees or so.

Case Study: This 52 year-old female sought a more defined jaw angle shape to improve her lower facial appearance. She had been through multiple previous jaw angle implant surgeries which were either complicated by implant malposition, infection or the placement of jaw angle implants that only provided a wider jaw angle but with no vertical elongation.

Female Jaw Angle Implants result left side view DR Barry Eppley IndianapolisUnder general anesthesia, her previous intraoral posterior mandibular vestibular incisions were used for access. Indwelling width only jaw angle implants were unscrewed and removed. They were replaced with vertical lengthening silicone jaw angle implants that added 9mm of vertical length with only 3mms of extra width. They were secured into placed with 1.5mm screws transcutaneously placed. After the incisions were closed a submental chin reduction was performed with a horizontal reduction of 7mms.

Female Jaw Angle Implants result right side view Dr Barry Eppley IndianapolisFemale Jaw Angle Implant results front view Dr Barry Eppley IndianapolisHer results at three weeks after surgery showed a more defined lower third of her face. Her jaw angles were lower with a sharper and more obtuse jaw angle shape. The chin reduction helped produce a less pointy chin that blended in well with the stronger back part of her jaw.

Besides the aesthetic improvements that can be obtained in women with the creation of vertical jaw angle enhancement is the side benefit of providing skeletal support to sagging tissues. The additional soft tissue that is needed to cover a longer jaw angle inevitably comes from the neck. This can help to pick up loose skin from the neck and fill out side of the face ‘deflation’.

Case Highlights:

1) For women that prefer a stronger jawline appearance, lowering the jaw angles with implants can produce a more defined lower third of the face.

2) Vertical lengthening jaw angle implants drop down the back part of the lower jaw giving women a less steep mandibular plane angle.

3) Strong jawlines in women have become more popular but it is important to appreciate that this is often more of a vertical jaw angle change rather than a width one.

Dr. Barry Eppley

Indianapolis, Indiana

December 11th, 2014

Plastic Surgery Products – Bellafil Injectable Filler

 

Over the past decade there have been many new injectable fillers that have become available for clinical use. And just about every year a new one is commercially released either by an existing or new manufacturer. As we end 2014, there is a new injectable filler that has become available…although it is new in name only.

Bellafil Injectable Filler Dr Barry Eppley IndianapolisArtefill (which originally was called Artecoll before becoming Artefill) has changed its name now to Bellafil in the U.S.. It appears the company (Suneva Medical) opted for the name change because it better describes the outcomes associated with the filler and provides the opportunity to rebrand the filler product.

Bellafil Artefill Injectable Filler Indianapolis Dr Barry EppelyAmongst the wide array of injectable fillers, Bellafil is unique in that it is a semi-permanent particulated type material. Bellafil is a combiantion of polymethylmethacrylate (PMMA) microscpheres and collagen. The ratio is 80% collagen and 20% microspheres. The collagen in Bellafill acts as a carrier for the microspheres and allows them to flow through a needle in a near laminar pattern. While the collagen does eventually resorb and go away, the PMMA microspheres are permanent and induce an ingrowth of collagen to create a permanent matrix for lasting volume improvement.

Since each injectable treatment results in only a 20% to 30% volume retention of the initial injection, repeated treatments are usually needed to build up ‘layers’ over time. This eventually results in a permanent volume result. This feature is what makes Bellafil distinctive from almost all other injectable fillers.

Bellafil was originally approved (as Artefill) in 2006 for the treatment of nasolabial folds or smile lines. Because of its bovine collagen carrier, patients should be skin tested before treatment to ensure they have no allergic reactions to it.

Dr. Barry Eppley

Indianapolis, Indiana

December 8th, 2014

Plastic Surgery Case Study: Visual Obstruction Treated By Browlift And Blepharoplasties

 

Background: Changes around the eyes are the earliest signs of facial aging. As a result, the ongoing aging effects often creates severe changes around the eyes as one enters their sixties. Besides the excess skin of the upper eyelids and the lower eyelid bags, the eyebrows often sag downward magnifying the hooding effect on the upper eyelids.

Visual Field testing Indianapolis Dr Barry EppleyHooding of upper eyelid skin and brow sagging do have functional effects. By weighing down the upper eyelids there is a loss of a portion of one’s visual fields. A portion or all of the upper visual field may be lost as the position of the upper eyelid acts like a blind over a window. Partial closure of the blind results in loss of one’s ability to see what lies above as one is looking straight forward. This is often confirmed by an historic test known as Goldman’s visual field examination which evaluates the entire range of peripheral vision. But automated perimetry testing today has replaced the traditional Goldman method in many ophthalmology/optometry practices.

To correct these severe eye aging effects and to improve one’s upper peripheral vision, multiple procedures need to be done. With brow sagging, an upper blepharoplasty alone (while helpful) may induce one to remove too much upper eyelid skin and severely shorten the distance between the eyebrow and the lashline. (in essence even pulling the eyebrow down further) A browlift combined with an upper blepharoplasty is needed to not only lift up the low brows but to also reduce the amount of upper eyelid skin that really needs to be removed. Together they create a periorbital effect that is better than a browlift or an upper blepharoplasty alone.

Case Study: This 62 year-old female was bothered by the way her eyes looked and how ‘old’ her appearance. She had such severe hooding that her upper eyelid skin hung below her lashlines. The weight of her upper eyelids, combined with some brow sagging, created a pseudo ptosis look as the level of her upper eyelids enchroached on the iros of the eye.

Visual Field Obstruction Blepharoplasties result front viewVisual Field Obstruction Browlift Blepharoplasties result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, an initial browlift was performed using a pretrichial incisional approach. An irregular zigzag incision was used along her frontal hairline. A total of 8mms of vertical upper forehead skin was removed for a moderate browlift effect. An upper blepharoplasty was then done using marks done before surgery based on pulling the brows upward. Lastly, lower blepharoplasties were performed with skin and fat removal, orbicularis muscle resuspension and lateral canthopexies.

Visual Field Obstruction Blepharoplasties result side viewHer results at six weeks after surgery showed a significant improvement in the appearance of her eyes but without an overdone look. Her lower eyelids had good contact with the globe and the position of the outer corner of her eyes was maintained. She did have some mild dry eye symptoms during the first month after surgery even though she had no ectropion or eyelid malpositioning problems. This is not rare when upper and lower blepharoplasties are combined with a browlift as this will slow the blink reflex for a period of time after surgery.

Case Highlights:

1) Severe aging around the eyes results in brow sagging and upper eyelid hooding which does impact one’s superior visual fields.

2) Optimal correction of visual field obstruction requires a combined brow lift and upper blepharoplasties.

3) Lower blepharoplasties are often done at the same time to enhance the overall periorbital aesthetic effect but do not provide an improvement in peripheral vision.

Dr. Barry Eppley

Indianapolis, Indiana

December 7th, 2014

Complications in Rib Graft Rhinoplasty

 

While rhinoplasty is a very common aesthetic facial procedure around the world, most do not require a large amount of cartilage grafting. But certain types of augmentative rhinoplasties in some ethnic groups do (e.g., Asian noses) and only the ribs can supply an unlimited amount of donor cartilage. While some rhinoplasty surgeons feel very comfortable harvesting and using ribs, many do not. Both donor and recipient complications can occur with their use but the actual incidence of their occurrence has never been studied in large patient numbers.

In the Online First Section of the November/December 2014 issue of the JAMA Facial Plastic Surgery journal, an article was published entitled ‘Complications Associated With Autologous Rib Cartilage Use in Rhinoplasty – A Meta-Analysis.’  In this paper, the authors performed a review of the potential complications associated with using autologous rib cartilage in rhinoplasty surgery. This was done by reviewing published articles on the topic from 1946 to 2013. Qualified papers included clinical studies with at least 10 patients and at least one after surgery complication from either the autologous rib recipient or donor site.

The paper included ten clinical studies with just under 500 patients. Using meta-analysis, the occurrence of recipient site complications include a 3% incidence of rib warping, a very low rate of rib resorption (0.2%), 0.4% for graft displacement, 0.6% for infection, and a 14% rate of revisional surgery. The occurrence of donor site complications included a 5% rate for poor chest donor site scarring and a 0% occurrence for pneumothorax.

This study did not necessarily reveal any new complications from using rib grafts in rhinoplasty but their various occurrences merit discussion. I was surprised that the warping of rib grafts was so low. Depending upon how you define the level of symptomatic warping, my experience is that is it somewhat higher than a few percent. Warping of ribs is a reflection of the donor site and the skill of shaping the harvested rib graft as well as the size of the rib graft.  Rib graft resorption occurred very rarely and this is no surprise given the low cellularity and metabolic activity of this type of tissue. (the only rib grafts I have ever seen resorb is in the face of infection) Similarly, infection in nasal rib grafting was also very low. (I have actually only seen it occur twice)

Hypertrophic chest scarring was seen in one out of twenty patients (5%) and is probably a reflection of the predominant Asian population which undergoes this type of augmentative rhinoplasty. Skin type and length of the harvest incision are major determinants of this complication. Pneumothorax is the most feared complication in rib grafting harvesting for any reason but it really shouldn’t be as this paper shows. When grafts are taken at the subcostal rib area, the apex of the lung lies way above it and there is no risk of violating the lung pleura. When taken at the inframammary breast fold in women, which is much higher, the lung is directly underneath but even small pleural tears do not result in any obvious pneumothoraces.

Like all rhinoplasties, the revision rates are fairly high and adding a rib graft to it only adds to the potential for postoperative aesthetic issues. At a near 15% rate, revision rhinoplasty includes such issues as revising warped and malpositioned grafts as well as graft edging and projection issues. Adding projection of the tip also exposes the risks of nostril asymmetry and alar rm retraction.

Dr. Barry Eppley

Indianapolis, Indiana

December 6th, 2014

Plastic Surgery Case Study: Occipital Bone Augmentation with Neck Fat Injections

 

Background: One of the most common aesthetic skull deformities is a flat back of the head. Caused by either genetics or external deformational forces in utero or after birth, the lack of adequate projection in the occiput can be aesthetically disturbing to some people. While often camouflaged by hair, it can still be a concern and is even more so by men who shave their heads or have very short hair.

Like forehead augmentation on the opposite side of the skull, occipital augmentation can be done by a variety of materials and techniques. By far the best occipital contouring technique is the use of a custom implant made from the patient’s 3D CT scan. This has become a very popular method used today due to its prefabrication of shape and thickness as well as the ability to limit incision size. But not everyone can use a custom implant approach for a variety of reasons. In these cases the traditional technique of implanting PMMA bone cement is used with intraoperative shaping and contouring is done. This requires no presurgical lead or fabrication time.

Back of Head AnatomyDespite the success of occipital augmentation surgery, some patients would like the augmentation to extend lower. Without realizing it their desired zone of enhancement is off of the bone and onto the neck muscles. Most people do not realize that the bottom end of the occipital bone (nuchal line) is at the level of the upper 1/3 of the ear. Thus bone cements can not be extended that low. Any augmentation below this back of the head level (which is not that commonly requested) must be done by soft tissue augmentation methods.

Case Study: This 26 year-old male had been bothered by his flat back of the head since he was a teenager. In determining his back of the head augmentation goals, which he provided by drawings, it could be seen that he wanted an augmentation effect that went below the nuchal line.

Fat Injections Neck Dr Barry Eppley IndianapolisUnder general anesthesia, a 9 cm curved incision was made at the upper back of the head. From this approach, wide subperiosteal undermning was done over the entire back of the head down to the nuchal line. Using 60 grams of antibiotic-impregnated PMMA bone cement, it was applied on the back of the head and the scalp flap was used to shape it as it set. Once the scalp incision was closed, small cannula liposuction fat harvesting was done from his lateral thighs. (his preferred choice) The 120cc lipoaspirate was concentrated down to 30cc which was then injected into his posterior neck at the subcutaneous level below the nuchal line down to the bottom of the hairline.

Occipital Skull Augmentation with Neck Fat Injections result Dr Barry Eppley IndianapolisMore complete occipital augmentation requires a hard and soft tissue approach. The use of fat injections is the only method for augmenting the lower portion of the flat back of the head. It may not be as reliable as bone cement for a permanent augmentation effect but it can be placed with an injectable technique. It can provide some moderate volume to complement a more profound upper occipital augmentation.

Case Highlights:

1) Occipital (back of the head) augmentation can be done by a variety of materials of which PMMA bone cement is the most economical.

2) The extent of occipital augmentation ends inferiorly near the nuchal line at the base of the skull which lies roughly at the level of the top of the ear.

3) Augmentation below the nuchal line must be done with fat injections over the neck muscles.

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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