Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
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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.

January 30th, 2015

Cooling Gel Masks After Blepharoplasty (Eyelid) Surgery


The eyelids are very thin tissues that are well known to swell and bruise easily. Because one’s eyes are so visible, every upper eyelid surgery patient would like their bruising and swelling to go away as soon as possible. For this reason, it is standard practice to do several after surgery strategies including cold compresses, head elevation and the oral intake of Arnica. While no one after surgery strategy is known to be universally effective, it is commonly believed that cooling or cold would be the most important.

Eye Masks for Blepharoplasty Surgery Dr Barry Eppley IndianapolisThe use of eye cooling has led to a wide variety of gel compresses for the eyes for blepharoplasty patients. Most are composed of a gel material that retains cold for a period of time after being removed from the refrigerator or freezer. The historic cooling regime was frozen vegetables (such as peas or corn) but gel pads are lighter and easier to use

In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘The Effect of Eyelid Cooling on Pain, Edema, Erythema, and Hematoma after Upper Blepharoplasty: A Randomized, Controlled, Observer-Blinded Evaluation Study’ was published. In 38 consecutive patients who had upper blepharoplasties performed, one side was cooled with an ice pack and the other eyelid was left uncooled. Evaluations were done on the degree of pain, edema, erythema, and occurrence of hematoma one hour, one day, one week, and two months after surgery. Light photography was used one week after surgery to determine the degree of bruising.

The results showed showed no difference in pain between the cooled and uncooled eyelids on the day of surgery. Pain in the cooled eyelids was significantly lower one day after surgery. No differences were seen in swelling, bruising or occurrence of hematoma between the cooled and uncooled eyelids at any time point in the study. The authors conclude that because the majority of patients had no preference for cooling over noncooling, eyelid cooling after upper blepharoplasty is not necessary.

Upper Blepharoplasty Indianapolis Dr Barry EppleyThis study casts doubt on a very long-held and logical treatment after upper blepharoplasty surgery. It just seems so logical that cooling/cold therapy would be beneficial that it is hard to believe that it isn’t. Despite what this study shows I doubt few plastic surgeons will abandon it. Particularly since it is a very low cost treatment that at the least has psychological value for the patient.

Dr. Barry Eppley

Indianapolis, Indiana

January 29th, 2015

Silicone Breast Implant Rupture Is A Misnomer


Now that silicone breast implants have been back in clinical use for almost a decade (since 2006), they have rapidly become more commonly used than saline breast implants.  Their more natural feel and the ability to last longer are amongst several important considerations for their favor over saline filled devices.

But the most compelling feature that silicone breast implants have which make them preferred is that they will never suffer spontaneous deflation. Saline implants are essentially bags filled with water which, should a small hole or tear develop in the bag, will allow its liquid contents to come out. Thus the implant will deflate and the overlying breast will become flatter.

Conversely, silicone can not suffer deflation because its contents are not a flowing liquid but a cohesive silicone gel. Silicone implants can fail and that is often called a rupture from a hole or tear in its lining. But the term ‘rupture’ should actually never be used because that is not what actually happens to a silicone breast implant when it fails.

Silicone Breast implant Disruption Dr Barry Eppley IndianapolisThe term rupture is defined and perceived as a forcible disruption or bursting effect. And that is not what happens to a silicone implant at all. Rather even a larger tear in the implant shell is only associated with an intermittent bulge of material when pressure is applied. (squeezed) When the pressure is removed, the gel material returns back into the confines of the implant shell. Even when a  silicone implant is cut it off, it still keep its form.

Due to the highly cohesive nature of today’s silicone breast implants, its failure should no longer be termed a rupture. Rather it is better described as a shell disruption or loss of integrity. This indicates the more benign event and outcome that results from this eventual expected event for many women after years of implantation. Rupture suggests breast implant contents that are lost when the current gel cohesivity no longer permits that to happen.

Dr. Barry Eppley

Indianapolis, Indiana

January 27th, 2015

Plastic Surgery Case Study – Lower Buttock Tucks


Background: The shape of the buttocks can take on many different forms. The buttocks have three different sections, the upper buttock, the mid buttock, and the lower buttock. Each buttock section has its own distinct shape. What separates the lower buttocks from the other two sections is the infragluteal fold. This fold makes a usually clear demarcation between the lower buttocks and the thigh below it.

Buttock Shape Dr Barry Eppley IndianapolisThe infragluteal fold or sulcus has been studied anatomically and histologically and has been shown to consist of strong fibrous bands extending from the underside of the skin (dermis) of its medial third to the ramus of the ischium and sacrum forming the letter J. The infragluteal fold, which attaches to both the ischium and the sacrum in a continuous fashion, is an anatomic structure in its medial part and only a crease laterally. It largely disappears in its lateral third as it approaches the outer thigh.

The infragluteal fold is one of the major concerns in reshaping of the buttocks. If an intact infragluteal fold exists with overhanging skin, then a lower buttock lift or tuck is needed. This is often called the butterfly lift if the central part of the buttocks sags with significant obscuring of the infragluteal fold. When the infragluteal fold is lost and the entire bottom of the buttocks sags onto the thighs with skin rolls, then wider excision of sagging skin with recreation of the fold is needed. It is important to remember that these excisional procedures only changes the shape of the lower buttocks and does not increase buttock volume or projection in any way.

Case Study: This 35 year-old female wanted to improve the shape of her buttocks. She was happy with her buttock volume and projection but felt the bottom had ‘fallen down’. She had an intact and defined infragluteal fold but her lower buttocks sagged over it.

Lower Buttock Lift (Fold Effacement) Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, an excision was done using the existing fold as the inferior aspect. A predetermined and measured line has been previously marked in the standing position to serve as the superior incision line. This wedge of tissue was removed keeping it from extending out too far laterally. Deep dermal sutures attached the superior line down into the existing fold level to rid the buttock overhang.

Lower Buttock LIft (Fold Effacement) back view Dr Barry Eppley IndianapolisThe lower buttock lift when there is an intact and well positioned infragluteal fold is better termed a lower buttock tuck. A true lift is when the nfragluteal fold is lost and has to be recreated.

Case Highlights:

1) Sagging of the buttocks takes on several forms depending on the location and prominence of the infragluteal fold.

2) A prominent infragluteal fold with overhanging lower buttock tissue creates a type 1 buttock ptosis deformity.

3) A lower buttock tuck removes overhanging tissue and creates a smoother transition between the buttocks and the posterior upper thigh.

Dr. Barry Eppley

Indianapolis, Indiana

January 26th, 2015

World of Plastic Surgery – Estonia


Estonia Plastic Surgery Dr Barry EppleyEstonia is a country in the Baltic region of Northern Europe. It is bordered by the Gulf of Finland to its north, Russia to its East, Latvia to the South and the Baltic Sea to its West. It is one of the smallest countries in Europe with a population of around 1.3 million and a land mass of only 17,000 square miles. Its capital is Tallnin with a population of over 400,000. It has a long history of having been occupied by numerous countries but gained its independence from Russia in 1991.

Skype Plastic Surgery Dr Barry Eppley IndianapolisIt is considered a high income economy with an average per capita income of over $20,000. A balanced budget, very low public debt, a flat-rate income tax, free trade regime, competitive commercial banking sector, innovative e-commerce servies and even mobile-based services are all hallmarks of Estonia’s market economy. It is seen as a very wired country with the development of the software for the popular Skype having been done in Estonia.

Tallnin Estonia Plastic Surgery Dr Barry EppleyThere are just around 20 plastic surgeons in Estonia. Most of which are in he capital city of Tallnin or in Tartu, the location of the country’s major medical university and training center. All of the most common plastic surgery procedures are performed in the country and costs that are comparative to many other European countries. Plastic surgery consultations can be done from as low as 11 euros and up to 75 euros. Pricing for many procedures can easily be found such as breast augmentation (3900 to 4200 euros), rhinoplasty (2850 to 3700 euros), liposuction (250 to 500 euros per area), chin augmentation (1700 euros), full facelift (3900 euros), and tummy tuck with liposuction (3850 euros) to name a few.

Dr. Barry Eppley

Indianapolis, Indiana

January 25th, 2015

Plastic Surgery Products: Ocumend Gel Pads for Facial Recovery


Bruising is a common sequelae of many aesthetic facial surgeries. While all bruising eventually goes away on its own, every patient would like it to be sooner rather than later. Besides surgical technique, the use of cold compresses and oral Arnica taken before and after surgery have been the most commonly used strategies for both prevention and the treatment of bruising and swelling.

Ocumend Gel Pads Dr Barry Eppley IndianapolisOcumend gel pads (Cearna Aesthetics) provide a topical hydrogel pad that contains Arica and Ledum. While Arnica is a well known homeopathic remedy, Ledum is less well known. Derived from the wild rosemary herb, Ledum is useful in healing bruising around the eyes as well as has antiseptic properties. The gel pad is purported to deliver fifty times the concentration of Arnica over other topical preparations. A recent study showed that Ocumend improved healing times in blepharoplasty and rhinoplasty surgery patients. Blepharoplasty patients had less swelling and bruising at one week after surgery than those patients that did not use the gel pads.

Ocumend Gel Pads Indianapolis Dr Barry EppleyOcumend gel pads are applied right after the procedure and are worn as much as possible the first day after surgery. They are then applied at night for the next five days to a week. They contain no adhesives so there is no residue left behind on the skin.

Dr. Barry Eppley

Indianapolis, Indiana

January 25th, 2015

Lovenox for DVT Prevention in Tummy Tuck Surgery


Tummy Tuckj Surgery Indianapolis Dr Barry EppleyDeep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) is the most dreaded complication of tummy tuck surgery. For that matter it is an increased risk for any aesthetic surgery around the abdomen/pelvic regions that involves compression (binder/garments) and any period of immobility after the procedure.While it is rare, it can occur and is a postoperative problem that has gotten a lot of attention recently.

There are a variety of before and after surgery considerations that can increase the risk of developing a DVT and/or PE. Genetics/family history, current medications (e.g. birth control pills), lack of movement after surgery and fluid levels (dehydration) can all contribute to an increased tendency for blood flow to slow down and have an increased tendency to clot.

Of all aesthetic plastic surgery procedures, the tummy tuck is at the highest risk for DVT/PE. The binding of the abdomen, the discomfort of muscle plication,the increased pressure on the vena cava and the subsequent tendency for limited early mobility after surgery are a potential setup for slowed venous blood flow return from the legs. If you factor in other adjunctive procedures like liposuction of the thighs and hips, and the subsequent circumferential binding used, the risks are further increased.

Lovenox Injections Indianapolis Dr Barry EppleyThe most common DVT preventative medication used for tummy tuck surgery and other high risk patients is Lovenox. Known generically as Enoxaparin, Lovenox is a low molecular weight heparin that is given by subcutaneoous injection. It works by binding to and increasing the activity of antithrombin III. By so doing it inhibits coagulation factor Xa. Since factor Xa assists in the conversion of prothrombin to thrombin, decreased thrombin levels prevent the formation of fibrin clots.

There is certainly a debate whether every tummy tuck patient should get Lovenox or just those that are at the highest risk. That is an individual plastic surgeon’s decision. The prophylactic dose of Lovenox is 30 mg subcutaneous injection twice daily with the initial dose administered within two or three hours of surgery and continuing for one week thereafter. There is no specific dose for weight-based Lovenox for use as DVT prophylaxis but most surgeons do not exceed 0.5 mg/kg every 12 hours.

Lovenox is historically expensive but generic versions (enoxaparin) have become available which dramatically lowers the cost. Insurance often covers its use but for an aesthetic surgery it may not be covered.

Dr. Barry Eppley

Indianapolis, Indiana

January 25th, 2015

Plastic Surgery Products: Dermapen 3 for Skin Needling


Almost everyone is familiar with laser resurfacing and its improvements offered by today’s concept of fractional laser resurfacing. By cutting into the skin layers in closely spaced holes created by a laser beam, improved skin quality results through collagen regeneration and remodeling. While there is no question about the benefits of fractional laser resurfacing, other non-laser devices can create similar patterns of skin ‘holes’

Dermapen Skin Needling Dr Barry Eppley IndianapolisOne of these devices is Demapen 3. This is a mechanized device use to fractionally rejuvenate the skin. Its tip contains 12 microneedles in a spring loaded sterile cartridge which is single patient use. The depth of needle penetration can be adjusted to go as deep as 2.5mms if desired. With 12 needles and an oscillating vertical motion with a top speed of 108 movements per second, 1,296 skin holes can be created per second to create a fractional skin rejuvenation effect. With the creation of some many skin holes, topical nutrients/agents (e.g., PRP) are applied and theoretically absorbed into the skin via the open channels. Interestingly, the oscillation movements helps dampen the transmission of nerve pain fibers making the treatments possible with little or no topical anesthetic.

Because Dermapen 3 does not create heat to make the channels (unlike a laser), it is safe to use on all skin types with no risk of post-inflammatory hyperpigmentation and a more rapid recovery period.

Like fractional laser resurfacing, Dermapen can treat a variety of skin issues from the treatment of wrinkles, skin texture irregularities and acne scars.  Its use is being increasingly used for hypertrophic scars, vitiligo and in the treatment of alopecia for hair regeneration.

The role of skin needling, which has been around for decades, has taken a quantum leap forward with Dermapen technology. This mechanized handpiece offers a more consistent method of making skin channels and has a real role to play alongside fractional laser resurfacing. For those patients who want less recovery and a lower treatment cost than that of lasers, Dermapen skin needling offers an effective alternative.

Dr. Barry Eppley

Indianapolis, Indiana

January 24th, 2015

Physiologic Tissue Adaptation to Face and Body Implants


Synthetic implants  are involved in some of the most common procedures performed in plastic surgery. From the skull down to the calfs, implants allow an instantaneous augmentation effect to be achieved of a variety of sizes and shapes. While rivaled more recently in some procedures by fat injection grafting, implants offers a permanent volume/augmentation effect that is simpler to achieve. (out of a box so to speak)

While implants offer many benefits, they also have their own set of potential complications. Infections, malposition and size issues are amongst the most common no matter where in the face and body an implant may be placed. These are obvious complications that occur in the short-term, within weeks or months after surgery.

But longer term changes which sometimes lead to complications with implants come about from a less obvious source. When a synthetic implant is placed in the body, the implant itself can never change as they are made of materials that do not degrade or change. (e.g., silicone) Rather the body must adapt to it and respond based on the pressure caused by the implant’s volume. Thus tissues change around the implant and these changes are almost always that atrophy. Surrounding tissues thin to varying degrees based on implant size and body location.

Chin Implant Settling Dr Barry Eppley IndianapolisOne of the classic examples of this response is that of the chin implant. Often erroneously referred to as ‘erosion’ (which suggests an inflammatory reaction which it is not) some chin implants can be seen on x-rays of being partially inside the bone. This is a benign but natural process of implant settling. As a response to the pressure of the chin implant, which causes its aesthetic effect by pushing off the underly bone on the soft tissues of the chin, the bone responds to this pressure over time by resorbing under the implant. This allows the chin implant to imprint into the bone. Once a ‘pressure release’ is obtained no further settling into the bone occurs. Interestingly it does not occur in all chin implants and rarely if ever occurs in any other type of facial implant.

Breast Implant Chest Wall Deformity Dr Barry Eppley IndianapolisAn often recognized example but one that is far more common is that of breast implants. The pressure release phenomenon occurs through the dual effect of overlying breast tissue thinning and underlying rib deformation. Every plastic surgeon has seen it in some women who undergo breast implant replacements. When the existing breast implant is removed, the remaining breast mound will look sunken in and deformed. This is one reason some women over time feel that their breast implants no longer look as big. The breast implant has never changed in volume but the surrounding breast tissue has become less and the implant may have settled down into the ribs more.

While this tissue response to chin and breast implants rarely causes any problems, such a response on the nose can be very problematic. Rhinoplasty that uses large implants for nasal augmentation is well known to cause thinning of the overlying soft tissues which is very thin. This can lead to implant exposure and infection.

Tissue atrophy and thinning occurs to some degree around every augmentative implant placed in the body. It usually does not cause any long-term problems but is one compelling reason to avoid very large implants at any face or body location.

Dr. Barry Eppley

Indianapolis, Indiana

January 23rd, 2015

Plastic Surgery Case Study: The Vertical Tummy Tuck


Background: The vast majority of tummy tucks can and are performed through a curved horizontal lower abdominal incision. (as well as around the umbilicus) There are, however, alternatives to this traditional excisional orientation in the right patient. A handful of patients may benefit from a vertical excisional approach.

When a vertical tummy tuck is typically thought of it is part of the ‘fleur-de-lis’ type. This is a tummy tuck where a vertical excision is combined with a horizontal one because there is too much side-to-side skin excess in the upper abdomen that cannot be addressed by a standard tummy tuck. This type of tummy tuck is almost exclusively used in massive weight loss patients.

Besides the fleur-de-lis pattern, there are other variations in which the vertical tummy tuck is completely vertical with no horizontal component.

Case Study: This 65 year-old female wanted to improve the shape of her stomach but did not want to commit to a traditional full tummy tuck. She asked if there was anything else that could be done. Her loose abdominal skin did not bode well for liposuction alone. But with her existing vertical scar from prior abdominal surgery decades ago, the concept of liposuction combined with some limited tissue removal became possible. This would allow liposuction to be performed and also deal with the skin laxity problem that would ensue.

Vertical Tummy Tuck results front view Dr Barry Eppley IndianapolisVertical Tummy Tuck result side view Dr Barry Eppley IndianapolisUnder general anesthesia, power-assisted liposuction was performed on her whole abdomen as well as out onto her flanks. Over 700ccs of fat aspirate was obtained. Then a vertically oriented ellipse of skin and fat was removed from the belly button down to the pubis incorporating her existing indented scar. Muscle plication was not deemed necessary at her age and desire for a short recovery. No drain was used.

Vertical Tummy Tuck result left side view Dr Barry Eppley IndianapolisHer recovery was uneventful with full return to all activities by three weeks after surgery. While she was still left with a vertical scar, which is how she started, the scar was no longer indented and smoother with the surrounding now flatter abdominal skin surfaces.

The vast majority of tummy tucks can be performed safely and effectively through a curved horizontal lower abdominal incision (and an incision around the umbilicus). However, there is a limited subset of patients for who may benefit from a vertical incision. This is certainly the case in someone who has an existing vertical incision.

Case Highlights:

1) Excessive skin and fat on the abdomen is not  a one-dimensional tissue problem.

2) A vertical tummy tuck removes skin and fat down the midline of the abdomen, most typically from the umbilicus down to the top of the pubis. (a mini tummy tuck)

3) A vertical tummy tuck works best in women who have an abdominal shape that is longer than it is wide.

Dr. Barry Eppley

Indianapolis, Indiana

January 20th, 2015

Stem Cells and Fat Injections in Plastic Surgery


Just recently the Food and Drug Administration (FDA) has approved a private company’s (Antria) Phase 2 clinical trial study for the use of fat-derived stem cells in plastic surgery. These trials are set to begin within the next three months. Antria received approval for Phase 1 clinical trials just under two years ago in March 2013.

Stem Cells and fat Injections Dr Barry Eppley IndianapolisAntria is the first company in the world to obtain FDA approval for human studies for stem cell-assisted facial fat grafting study. Antria’s patent-pending process uses liposuction to extract the fat. Within one hour, stem cells can be prepared from that fat. Antria’s process uses its proprietary Adipolyx solution, a collagenase-based reagent, to isolate stem cells from adult fat cells.

While this FDA approval is significant in and of itself, the even greater relevance is what this indicates for the widespread marketing of so-called stem cell procedures in plastic surgery. The reality is that there are really no true stem cell procedures in plastic surgery despite what is claimed or promoted on the internet and otherwise. Procedures touted as ‘stem cell-enriched’, ‘stem cell injections’ or ‘stem cell procedures’ in plastic surgery are misleading.

While fat does contain numerous stem cells, these are inadvertent passengers in what is otherwise and simply put fat injections. Extracting fat by liposuction and concentrating it for injection for soft tissue augmentation does not make it a bone fide stem cell treatment. This is a marketing tactic, which although very appealing to patients, implies properties of the injection treatment that it does not have.

fat injections to forehead dr barry eppley indianapolisFat injections have many benefits from adding soft tissue volume to improving the vascularity of the injected tissues. But whatever role the percentage of stem cells in the fat has in these benefits is highly speculative. That should not he confused with a highly concentrated and pure source of stem cells which is what is currently being studied in human clinical trials

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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