EXPLORE
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.

July 6th, 2015

Case Study – Skull Implant Browlifting Effect

 

Background: Skull implants are used today to treat a variety of aesthetic head shape concerns and deformities. While many think of skull implants of filling in craniotomy or other traumatic skull defects, aesthetic skull implants are placed in a subperiosteal onlay fashion to build out usually normal thickness skull bone areas. Skull implants placed in this manner are used for correcting skull asymmetries, flat spots, irregularities or just to create an overall larger circumference to the head.

Skull Cap Imnplant Design Dr Barry Eppley IndianapolisThe success of skull implants is partially dependent on the overlying scalp. The scalp has to stretch to accommodate what is placed beneath it. The skull implant can not be too large or too thick or the scalp will be too tight and the incision to place it will not be able to be closed. The bigger the skull implant or the larger the skull surface area that it covers the more that the scalp tissue is ‘recruited’ from elsewhere as the overall scalp stretches to accommodate the implant pressure underneath it.

Interestingly, some patients think that a skull implant will naturally have a bit of a facelifting effect. They envision that the upper pull of the scalp will translate into a distant effect low on the face. This is not what occurs, even in the largest of skull implants that I have placed. But there are certain circumstances with skull implants where a browlifting effect can be created.

Case Study: This 42 year-old female presented for a combination of forehead contouring and a near circumferential skull implant to build up the sides and the back of the head. A custom skull implant was designed with maximal thickness of 8mms in the back.

Skull Implant Browlift result front viewSkull Implant Browlift result oblique viewUnder general anesthesia, a pretrichial incision was made. Going anteriorly the slope of the forehead was reduced by bone burring. Going posteriorly the scalp was elevated over the temporal and occipital regions of the scalp. The custom made implant was inserted, trimmed where needed and secured with small titanium screws. Prior to placement multiple perfusion holes were placed through the implant.

Skull Implant Browlift result side viewHer postoperative results showed a larger circumference to the head but also that she had developed a significant browlifting effect. This was a desireable aesthetic side effect of the skull implant. It occurred most likely because the access point for the implant’s insertion was at the frontal hairline. (pretrichial incision) As the scalp behind the incision became elevated, closing the pretrichial incision (after elevation of the forehead flap and contouring) resulted in the brows moving upward.

Highlights:

1) Skull implants of substantial size can elevate the scalp through underlying volume addition.

2) If a skull implant is placed close enough to the frontal hairline and of sufficient size it can have a browlifting effect.

3) The pretrichial approach to skull implant placement can both contribute to a browlifting effect from skull implants or can be used to create a browlift if desired.

Dr. Barry Eppley

Indianapolis, Indiana

July 5th, 2015

Case Study – Small Natural Breast Augmentation

 

breast involutionBackground: Many may perceive that breast augmentation is about getting bigger breasts  but for many women is merely about getting back to what they once had. Usually due to pregnancies and breast feeding, a woman’s actual breast volume will almost always become less through a normal biologic phenomenon known as involution. This may not be so evident after one pregnancy but becomes more manifest with two or more pregnancies.

Besides fat injections, saline or silicone gel breast implants are the only surgical method to restore lost breast volume. What size implant a women desires is a personal choice and many women will end up picking an implant size that is bigger than they were before having children. If one is going to have surgery and incur costs and recovery one might as well be better than how one was originally made.

But this is is not true for all postpartum women undergoing breast augmentation. Some women may only want to get back what they had lost. An implant can do that well provided that the soft tissue envelope of the breast is not overly stretched and sagging. If some sagging exists more breast volume than desired may be needed to fill it out adequately.

Case Study: This 28 year-old female presented for breast augmentation. She has her last and final child six months ago. She opted for a silicone implant to get the most natural feel given her nearly complete lack of any breast tissue.

small breast augmentation result front viewsmall breast augmentation result oblique viewUnder general anesthesia, she had 270cc silicone gel breast implants placed in a dual plane position from inframammary incisions. They were of moderate profile with a base width of 11.5cms. While she had a bit of breast skin sag beforehand her nipples remained largely above the lower breast creases.

small breast augmentation result side viewBreast augmentation can be modest and can be done to just fill out the deflated breast envelope. This can also create a bit of a ‘breast lift’ with the volume expansion. This is not a true breast lift per se as it is just lifting up the nipple through restoration of previous breast volume.

Highlights:

1) Breast augmentation for many women is only about restoring lost breast volume, not necessarily being bigger than they originally were.

2) Small breasts that have lost volume from pregnancies only need a small breast implant, often below 300cc.

3) As long as there is no ptosis (sagging) and the nipple is above the inframammary fold a small breast implant will adequately restore breast volume.

Dr. Barry Eppley

Indianapolis, Indiana

July 4th, 2015

Three-Dimensional Jaw Angle Surgery

 

Changing the mandibular jaw angle can be one of the most challenging of all aesthetic facial skeletal surgeries. It is a tight space to work in from an intraoral approach and visualization is almost always suboptimal. Loupe magnification and a head light would be considered critical in any type of jaw angle surgery particularly that of bone reshaping/reduction.

Jaw Angle OstectomyWhile jaw angle reduction is not a commonly performed aesthetic procedure in Caucasians, it is extremely common in Asians who frequently have a more square face with prominent jaw angles. Thus there have been many variations in the Asian plastic surgery literature as to how to perform an ostectomy of the jaw angles. Given the difficulty in performing the procedure there is no universally described method that can completely avoid uneven or asymmetric posterior mandibular contours.

In the July 2015 issue of the Annals of Plastic Surgery, the article entitled ‘Endoscopic-Assisted Intraoral Three-Dimensional Reduction Mandibuloplasty’ was published. In this paper the authors describe a jaw angle reduction technique done in over 100 patients over a three year period. This was a one-stage long-curved ostectomy combined with a splitting corticectomy done through an intraoral approach with the assistance of an endoscope. The one-stage long-curved ostectomy and corticectomy were performed using an oscillating saw with angles of various degrees and length under direct vision. Their results showed good three-dimensional changes to the jaw angle with lower facial width reduction. Patient satisfaction was high. These changes, as would be expected, increased the height of the gonial angle and the mandibular plane angle as well. No major complications occurred from bone fracture to facial nerve injury.

The value of the endoscope is not clear from reading this article but what is most evident is that effective reduction of the jaw angle requires a combination of bony techniques. The actual jaw angle must be removed and the bone thinned by removing the outer bony cortex. This can make the face look thinner from the front view and have a smooth line from the side view. The jaw angle will get higher and there is the risk of loss of some soft tissue support so over resection of bone should be avoided.

Dr. Barry Eppley

Indianapolis, Indiana

July 4th, 2015

Case Study – More Than A Hump Reduction Rhinoplasty

nasal hump anatomyBackground: People consider and undergo rhinoplasty for a variety of nasal shape reasons. But a hump on the bridge of the nose is the number one reason people seek to change the shape of their nose. Whether by intuition or cultural/beauty standards, there is a general desire to have a straight dorsal line of the nose. The bridge of the nose can be high or low but most importantly it must be straight to be aesthetically pleasing.

Many patients are unhappy about the hump on their nose but may otherwise be happy with its shape elsewhere. This understandably makes the patient request only a hump reduction type rhinoplasty. While this may seem to be reasonable it is often not appreciated that changing the shape on one part of the nose can affect how other parts look as well as the overall appearance of the nose.

While it is possible that hump reduction only can make for a better appearing nose, it is equally possible that it will unmask other nasal shape issues. Most commonly when a significant nasal hump is reduced, the nose may actually look longer and the tip may look undesireably downturned. This is why it is critically important before rhinoplasty to have computer imaging done to see how changing one aspect of the nose may affect the appearance of other nasal areas.

Case Study: This 28 year-old female had long been bothered by the bump of her nose. She just wanted it reduced the maximal amount and to almost have a bit of a concavity rather than a straight line. When looking at computer imaging however she realized that she needed the tip of the nose shortened and reduced as well to look right.

Hump Reduction Rhinoplasty result side view Dr Barry Eppley IndianapolisHump Reduction Rhinoplasty result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, she underwent an open rhinoplasty with hump reduction, spreader grafts to the middle vault, caudal septal shortening, and tip shortening and narrowing. When seen fifteen months after surgery she had a much better shaped nose with loss of the hump and a more proportionate tip shape and position. The columellar scar had healed nicely and it was not noticeable.

Hump Reduction Rhinoplasty result front view Dr Barry Eppley IndianapolisWhile hump reduction alone may be an appropriate isolated maneuver in rhinoplasty, one should have a full appreciation before surgery as to how that alone may affect the look of the nose. More times than not the decision to do more than just a hump reduction rhinoplasty alone will be made.

Highlights:

1) The reduction of hump or bump on the bridge of the nose is one of the most common reasons people undergo rhinoplasty surgery.

2) Reduction of a nasal hump may or may not be able to be done by itself but should first be determined before surgery by computer imaging.

3) Hump reduction often requires other nasal modifications, particularly in the tip, to give the best aesthetic nasal shape from a rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

July 3rd, 2015

Case Study – Brow Bone Implant Augmentation in Men

 

Background: One of the main characteristics of the male forehead are the brow bones. They usually are more pronounced than the projection of the forehead creating a brow bone break between the two structures. Brow bones occur in men due to the larger growth of the underlying frontal air sinuses, a result of a testosterone influence. Brow bone problems in men are more often the result of excessive overdevelopment rather than underdevelopment.

Building up a deficient or flat brow bones can be augmented by a variety of implanted materials. The simplest brow bone augmentation method is by fat injection. It can be placed without an incision and can be feathered the whole way down the lateral orbital rim. Its one disadvantage is that fat survival is unpredictable and often undergoes substantial resorption weeks to months after surgery.

A brow bone implant is a permanent augmentation method as its composition can not undergo any physical change. While there are a number of available materials the most versatile and easily made is that of silicone. Having worked with silicone brow bone implants over the years, a variety of ‘off the shelf’ implant designs have been used and can be applied to other patients as well. Ideally a custom made brow bone implant can be fabricated from the patient’s 3D CT scan and build out in shape and size to what the patient wants.

Case Study: This 32 year-old male was having a variety of facial reshaping procedures and brow bone augmentation was one of them. He had no brow bone prominence evident and a flatter forehead profile. He opted for a preformed brow bone implant placed through one of his low horizontal forehead wrinkles.

Mid-Forehead Incision for Brow Bone Implant Dr Barry Eppoley IndianapolisScrew Fixation of Brow Bone Implant Dr Barry Eppley IndianapolisUnder general anesthesia, the brow bones were exposed through a central horizontal forehead incision. The supraorbital and supratrochlear nerves were identified and retracted downward. The brow bone implant was inserted, positioned and secured with a single midline small screw. The forehead incision was closed in layers.

Brow Bone Implant result side Dr Barry Eppley IndianapolisBrow Bone Implant result oblique view Dr Barry Eppley IndianapolisBrone Bone Implant result front view Dr Barry Eppley IndianapolisWhen seen nine months after surgery he had a very noticeable brow bone ridge and brow bone break. The scar had healed nicely and it was not noticeable.

While brow bone augmentation is uncommon, its biggest issues are the implant’s design and how to get it onto the brow bones. (incision) The shape and thickness of the brow bone implant is best done through a custom manufacturing process. But I have done enough of these surgeries over the years that a number of different preformed brow bone implants are available. The real challenge is how to place it and the most common methid would be through an endoscopic approach from at the hairline or just behind it. In rare instances, like in this case, the patient will permit direct access through a horizontal skin incision just above the brow bone area.

Highlights:

1) Permanent brow bone augmentation can be done using a custom made brow bone implant.

2) Placement of a brow bone implant requires an open incision which can be done through a mid-forehead crease/wrinkle.

3) Brow bone implants are available in preformed shapes or can be custom made.

Dr. Barry Eppley

Indianapolis, Indiana

July 2nd, 2015

Case Study – Custom Pectoral Implant in Poland’s Syndrome

 

Background: The male chest is largely defined by the size and shape of the pectoralis muscle as well as the nipple-areolar complex. While chest asymmetry to some degree is common in many men, significant asymmetry is most commonluy caused by abnormal development. A variety of congenital male chest conditions exist including pectus excavatum and pectus carinatum as the most common occurring 1 to 400 to 1500 births.

Poland's SyndromePoland’s syndrome was described more than a hundred years ago is fairly rare occurring in more than 1 to 20,000 births. It really describes a spectrum of anterior chest wall deformities that can include the pectoralis major, pectoralis minor, serratus muscles as well as that of the ribs and even potentially extending to involve the arm and hand., ribs, and soft tissue. Deformities of the arm and hand may also be observed. It is far more common in men with a high ride sided occurrence. Poland’s syndrome presents in a wide ranging degree of expression from ver mild chest asymmetry with no arm involvement to the extreme of a flail chest and a short dysfunctional arm.

Reconstruction of many male Poland’s patients involves restoring/recreating the deficient pectoralis major muscle. This has been done historically by implants, muscle flaps and, more recently, fat injections. Each method has their own advantages and disadvantages as well as their own advocates. For smaller pectoral muscle deficiencies the choice of implants vs fat grafting are the logical (benefit vs risk) choices.

Case Study: This 30 year-old male was born with a mild manifestation of Poland’s syndrome that involved the left side of his chest. It was most evident by the loss of a well defined lower pectoralis major muscle border and smaller chest contour. A custom designed implant was made using a silicone elastomer molding technique and send for fabrication into a solid but flexible implant.

custom pectoral implant Dr Barry Eppley IndianapolisUnder general anesthesia, the custom designed pectoral implant was placed through a transaxillary incision. After multiple trial fits it was determined that it was slightly too big. It was reduced down in size using scissors. Using a copy of the location of the lower border of the pectoralis major muscle the implant was inserted into a carefully made pocket using a long dingman dissecting instrument. The limits of the pocket defined the final implant’s location so that it could not migrate either inferiorly or superiorly.

Left Custom Pectoral Implant Poland's Syndrome Dr Barry Eppley IndianapolisWhen seen six months after surgery he had much improved chest asymmetry and no detection that there was any implant in place. It looked perfectly natural . The lower border of the pectoralis major muscle has been restored.

Custom designed pectoral implants can provide a good method of Poland’s chest reconstruction but they must be designed properly and placed into a carefully made pocket. There are multiple ways to create a custom designed pectoral implant but the simplest, and probably most effective, is to make a silicone elastomer mold on the actual patient. The muscle deficiency must be carefully determined through arm motion with an understanding that it is very easy to oversize it.

Highlights:

1) Male chest asymmetry is not that common and one of the origins of it is Poland’s syndrome.

2) Reconstruction of the male Poland’s chest is to create pectoralis muscle volume and a defined lower muscular border.

3) A custom designed pectoral implant is a useful reconstructive method in the male Poland’s chest and often needs to be smaller than one would initially think.

Dr. Barry Eppley

Indianapolis, Indiana

July 1st, 2015

Case Study – Dermal Fat Grafting in Frontal Linear Scleroderma

 

Background: Forehead augmentation or reconstruction is most commonly done using either intraoperatively formed bone cements or a variety of custom designed implant materials. Such forehead implants work best when the overlying scalp tissues are thick and well vascularized. Forehead implant materials should be used with impeding peril when the soft tissue cover is compromised due to injury, resective surgery, or having been treated by radiation.

One well known but uncommon condition that affects the forehead is linear scleroderma.  (frontal linear scleroderma) This is a specific form of scleroderma that can affect the forehead and is believed to be an automimmune phenomenon. It presents as an evolving  linear band of soft and hard tissue atrophy that usually follows the course of the supraorbital nerve from the brow up into the scalp. It also has atrophic effects below the brow often down through the orbit. Because of its linear indentation appearance up through the forehead it is also known as morphea coup de sabre or ‘cut of the sabre’.

Reconstruction of frontal linear scleroderma has been done by a variety of techniques with the objective of restoring soft tissue thickness. This is usually more important than reconstruction of any bone defect which may exist as it is often a minor part of the forehead contour problem in many cases. Fat injections are the easiest and least invasive method which, while having to be repeated to get optimal take and contour result, do address the thin and atrophic skin which often has little fat underneath. Augmentation with bone cement fills in any bone defect along the linear bone depression but still leaves the soft tissue deficiency if just one alone.

Case Study: This 30 year-old female began to develop linear scleroderma around age 13 and it progressively became worse until it became stable (maximum atrophy) by her early twenties.  It involved the left eye, left brow and frontal bone and up into the scalp. A 3D CT scan showed that there was brow bone and frontal bone retrusion. The overlying soft tissues were very thin and atrophic. The skin was very thin and there was little subcutaneous fat between the skin and the bone. While bony forehead reconstruction was needed using bone cement the thinness of her soft tissues was of concern or using this reconstruction method alone..

Dermal Fat Graft Reconstruction Forehead abdominal harvest Dr Barry Eppley IndianapolisDermal Fatr Graft Reconstruction Forehead intraop result Dr Barry Eppley IndianapolisUnder general anesthesia, a large dermal-fat graft was harvested from a mini tummy tuck procedure. The overlying epithelium was removed and its thickness trimmed down to approximately one centimeter. Through a small scalp incision directly above the left forehead back in the hairline the dermal fat graft (dermis up) was passed over the bone and secured by external suture bolsters down over the brow bone aided by an upper blepharoplasty incision.

Dermal Fat Graft Reconstruction Left Forehead Dr Barry Eppley IndianapolisAt one year after the procedure the improvement in the brow and forehead area was very evident with thicker overlying soft tissues and improved brow and forehead contour.  This now makes the use of hydroxyapatite cement potentially less problematic with healthier overlying soft tissues.

Dermal-fat grafts are the oldest method of fat grafting and have been over shadowed (and sometimes forgotten) with newer methods of injectable fat grafting. Their biggest drawback is that they require an open excision and resultant scar to harvest and an incision to place them. One also has to have an adequate donor area from which they can be harvested. This is easier in women in large dermal fat grafts with some form of a tummy tuck than it is in men.

Highlights:

1) Forehead augmentation/reconstruction in forehead asymmetry can be done by bone cements or fat grafting.

2) Fat grafting forehead augmentation is best done in pathologic conditions where the forehead skin/tissues are thin.

3) Fat grafting in the forehead can be done by either injection or a dermal-fat graft method.

Dr. Barry Eppley

Indianapolis, Indiana

June 30th, 2015

Case Study – Long Terms Results of Subnasal Lip Lift

 

Background: Lip augmentation is one of the most popular non-surgical cosmetic facial procedures and is one of the most common sites for the placement of injectable fillers.  But injectable fillers only add volume and in the vermilion deficient lip may create a very pouty lip or ‘fish’ lips. Without adequate vermilion height the filler merely pushes the lip forward and not up as well.

For the vermilion deficient upper lip, there are several surgical procedures to change the location of the vermilion-cutaneous junction. Such change is instrumental in getting a good and natural lip augmentation effect. These two well known procedures are the lip lift and the vermilion advancement. The subnasal lip lift is, literally, a lifting procedure of the lip by removing a segment of skin from right under the nose. It achieves two important effects, shortening the lip-nose distance and creating more of a central lip pout. In some patients and with enough tissue removed more tooth show may also result. (but the risk of excessive tissue removal and a ‘chipmunk look’ can be created with too much  of a lip lift) It is equally important to appreciate that it is does not create a corner to corner lip change and only augments the portion of the nose that lies between vertical lines drawn from the sides of the nostrils.

There are several criticisms/concerns about the subnasal lip lift. Some feel that if only skin is removed there will be significant relapse.(recurrent lengthening) This has led to lip lift techniques that remove or tighten the orbicularis muscle which can lead to its own set of problems. (lip tightness, smile deformity) There is always the concern about the appearance of the scar right under the nose and whether it will deform the nostrils or the base of the columella.

Case Study: This 26 year-old female wanted a lip lift to shorten her lip to nose junction and provide some some additional central lip pout. She already had reasonably good vermilion fullness and did not need/want any direct vermilion augmentation. Given her greater skin pigment there was good presurgical discussion about the resultant scar.

Subnasal Lip Lift immediate result front view 2Subnasal Lip Lift immediate result side viewUnder local anesthesia, a subnasal lip lift was performed removing 25% of the distance of the philtral column. (4mms) Only skin was removed without any muscle manipulations. Only small resorbable sutures were used on the skin as she lived far out of town.

Subnasal Lip Lift long-term results front view Dr Barry Eppley IndianapolisSubnasal Lip Lift long-term results side view Dr Barry Eppley IndianapolisWhen seen one year later, the subnasal scar was barely detectable and there was no nostril/nose deformity. Comparing her immediate and one year pictures, the subnasal lip lift result has remained stable. (no change in the lip-nose distance or the amount of central lip pout)

The subnasal lip lift can be an effective procedure that has minimal risks if it is not overdone or involves muscle manipulation. It must be meticulously measured and executed to be both symmetric with a good scar outcome.

Highlights:

1) The subnasal lip lift is a surgical procedure for enhancing the central part of the upper lip and shortening the nose-lip distance.

2) The amount of relapse or recurrent skin stretching is 10% or less and is not that noticeable.

3) A skin excision (muscle sparing) subnasal lip lift is both safe and effective and has a very low risk profile.

Dr. Barry Eppley

Indianapolis, Indiana

June 28th, 2015

Case Study – Z-plasty for Eyebrow Lowering

 

Background:The eyebrows provide an important framing structure for the eye area. Residing over the brow bones (supraorbital rims) their hairy composition provide an instantly recognizeable facial feature. While eyebrows have very variable shapes and hair features, and they are subject to considerable grooming and modifications based on contemporary style, the one consistent and important feature of them is symmetry.

Asymmetry of the eyebrows is a very noticeable facial feature. Even the slightest amount of eyebrow asymmetry can be detected.  It has been shown that as little as 2mms of difference in eyebrow position is noticeable to patients. While some degree of slight eyebrow asymmetry is present in many patients who present for periorbital rejuvenation for example, they can be very effectively treated by Botox injections for improved symmetry and less eyebrow movement. This works because the eyebrows are dynamic and have muscles that can be temporarily blocked or inhibited from moving.

But eyebrow asymmetry that results from nerve paralysis poses a much more challenging problem. The paralyzed eye brow is a fixed structure that is elevated rather than depressed. It can not be made to drop down by Botox injections nor can a surgical release  like in a browlift made it become lower. Eyebrow asymmetry from a lower then normal brow position is a much easier to improve as the eyebrow can be raised by a variety of browlifting techniques.

Case Study: This 19 year-old male had surgery as a young child to treat a large forehead lymphangioma. While the lymphangioma was cured, the resective surgery left him with a permanent paralysis of the frontal branch of the facial nerve. This caused the eyebrow to be permanently elevated. The forehead tissues were very scarred and immobile from the prior surgeries.

Eyebrow Z-plasty Dr Barry Eppley Indianapolisz-plastyUnder general anesthesia, his left eyebrow was repositioned lower using a classic z-plasty  tissue rearrangement technique. The entire tail of the eyebrow was lowered by switching the skin and deeper tissues below it and changing places with it.

Left Eyelid Reconstruction with Transposition Flap Dr Barry Eppley IndianapolisEyebrow Transposition Flap Dr Barry Eppley IndianapolisAt three months after surgery all skin flaps were healed. No loss of amy of the tips of the skin flaps occurred. The eyebrow position was much more symmetrical to the other side albeit not perfectly symmetric.

The overelevated or paralyzed eyebrow is a difficult challenge to reposition as all conventional methods of eyebrow repositioning rely on normal muscle movements and supple forehead tissues. A z-plasty method of reconstruction provides a simple and effective method of eyebrow lowering if the patient is scar tolerant.

Highlights:

1) Symmetry of the eyebrows is an important aesthetic facial feature.

2) An eyebrow that is too high is a much more difficult reconstructive challenge than an eyebrow that is too low.

3) The tail of the eyebrow can be lowered by a traditional z-plasty tissue rearrangement technique.

Dr. Barry Eppley

Indianapolis, Indiana

June 27th, 2015

Case Study – Injection Fat Grafting for the Gynecomastia Crater Deformity

 

Background: Gynecomastia is a well known male chest abnormality that has a wide range of expression from puffy nipples to that of an actual breast mound.  It is treated by two basic approaches, liposuction and open excision. Which treatment method is sued depends on the size and tissue quality of the gynecomastia problem. Most commonly a combination of open excision through a lower areolar incision and more encompassing liposuction of the entire chest is done to get the optimal result.

The results of gynecomastia surgery is reflective of how much fat is removed and the evenness of its removal, regardless of the treatment method used. Both excision and liposuction are as much art as science as there is no way to know for sure as to how the tissue removal will ultimately look. While the plastic surgeon wants to get the most complete gynecomastia reduction, there is also the fear that too much tissue removed will cause the opposite problem. This would appear as an inward retraction of the nipple areolar complex known as the ‘gynecomastia crater deformity.’

While many early gynecomastia results may show a slight inward contour, these usually resolve on their own to a smoother appearance. But when excessive breast tissue is removed the inward retraction of the nipple-areolar complex becomes more obvious and pronounced as postoperative healing occurs. It is most manifest when one’s arms are raised as the adhesion between the underside the nipple-areolar complex and the pectoralis fascia causes a maximal retraction effect.

Case Study: This 38 year-old male had two prior gynecomastia reduction surgeries through an initial liposuction procedure followed by a secondary open excision procedure to get rid of some residual nipple puffiness. After the second procedure the nipples started to invert inward which became really evident with raising the arms. This continued to persist and did not change by six months after the second procedure.

Fat Injections for Gynecomastia Reduction Retractrion result front view Dr Barry Eppley IndianapolisUnder local anesthesia, fat was harvested from the lower abdominal area with small cannulas. It was concentrated by filtering and double washing into 40ccs. A small cannula was initially used to break up the scar and adhesions under the nipples and then fat was injected both under and around the nipple areolar complexes.

Fat Injections for Gynecomastia Reduction Retraction result oblique viewFat Injections for Gynecomastia Reduction Retraction result side viewAt three months after surgery his postoperative results showed improvement in the nipple areolar-chest contour and less nipple retraction. Fat take at this point would be assumed to be maximal. A second stage fat grafting is planned for further improvement.

When there is not an adequate buffer of tissue between the nipple and the pectoralis muscle, adhesion and scar contraction will occur. Correction of the gynecomastia crater deformity almost always requires release of the scar bands (adhesiolysis) and restoration of intervening tissue between the nipple and chest muscle. Injection fat grafting provides the easiest way to achieve both objectives. It could also be done through an open method using the lower areolar incision and placement of a dermal-fat graft. This approach poses more of a donor site harvest concern.

Highlights:

1) The gynecomastia crater deformity is caused by excessive breast tissue resection and scar contracture.

2) Gynecomastia defects can be successfully treated by injectable fat grafting which may require more than one session for optimal improvement of chest contour.

3) Injection fat grafting can be combined with PRP and Acell particles to optimize fat graft take.

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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