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.

October 21st, 2014

Case Study: Forehead Augmentation for Forehead Horns


Background: The desirable features and shape of the male forehead is well known. It consists of a brow bone prominence, a superior brow bone break and a smooth slightly convex shape of the upper forehead to the hairline. A wider or more square forehead shape is often seen as an asset as well. Some put great stock in the appearance of the forehead in a man and it certainly can have a strong or weak appearance depending on the shape of the frontal and brow bones which make up its bone structure.

Regardless of gender, one of the desireable features of an attractive forehead is having a smooth contour. Irregularities or indentations are easily seen on the forehead given its broad surface area. This is particularly true in men who do not commonly have a hairstyle that can completely obscure the forehead.

Central indentations of the forehead are not rare in men and are the result of natural development. When present they often create the appearance of upper forehead prominences or horns. This is an artificial appearance that exists mainly because of the depression between them and the lower brow bones. Those who have these forehead horns often feel they make one look older and cast a shadow on the forehead which makes it look uneven even thought the forehead horns aren’t really that raised.

Case Study: This is a 17 year-old male teenager who was bothered by the appearance of his forehead. It had an irregular uneven appearance and he was teased about how it looked. His forehead had a central horizontal depression between the upper forehead and the brow bones that made it look like he had two forehead horns.

Forehead Augmentation with Hydroxyapatite Cement intraop Dr Barry Eppley IndianapolisUnder general anesthesia a coronal scalp incision was used to access the entire forehead. The forehead was built up with hydroxyapatite cement, filling in the depressed area in the center of the forehead. This created a smoother frontal bone shape which also eliminated his superior brow bone break.

Forehead Recontouring result front viewForehead Recontouring result oblique viewHis results showed a much improved forehead shape with complete elimination of his forehead horns and any shadowing effect. His scalp scar was essentially undetectable across the entire length of the incision.

Case Highlights:

1) In some men, a depressed upper forehead accentuates their brow bone prominence and can even create the appearance of forehead ‘horns’ or prominences.

2) Forehead augmentation through hydroxyapatite cement can effectively smooth out indented forehead contours.

3) Forehead augmentation with bone cement needs to be done through an open scalp approach and can have very acceptable scar outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

October 20th, 2014

The Safety of Plastic Surgery in Older Patients


As the U.S. population ages and the growing acceptance of plastic surgery extends to all ages, older patients are now undergoing procedures more frequently than ever before. This raises the question of whether this is safe practice and are these older patients at an increased risk of complications because of their age. On the surface, age is associated with a perception of being weaker and more susceptible to disease and injuries.

Older Plastic Surgery - Plastic Surgery for the Elderly Dr Barry Eppley IndianapolisAt the annual meeting of the American Society of Plastic Surgeons in Chicago last week, a study was presented evaluating the rate of complications rate amongst younger vs older plastic surgery patients. In this paper, the CosmetAssuree company (independent insurance company that offers protection from the costs of medical complications for certain cosmetic surgery procedures) provided data over a five year period (2008 to 2013)  of their reported complications and their ages. Patients over 65 years old (mena age 69 years old) had a complication rate of 1.94% which was not statistically different than the 1.84% complication rate amongst younger patients. (mean age 39 years old) No differences in complication rates occurred despite the higher number of medical issues and weights in the older patient group. Even with looking at the upper ranges of the older group (80 years or older), the complication rate only rose slightly to 2.2%.

This study also showed that the proportion of facial procedures amongst the older group was much higher than in the younger group. (63% vs. 12%) It is no surprise that the older patients had more facial procedures than body contouring which is well known to tail off from age 60 and older. So to some degree the decreased rate of complications may have been partially altered by the procedural bias that happens with age. Despite that the length of a facelift may be just as long or longer than a tummy tuck for example, there are natural big differences in the rate and type of complications that can occur between a smaller face than the larger abdominal area.

But even looking at facial procedures, the older patients fared just as well. This has been previously reported in the June 2011 issue of the journal Plastic and Reconstructive Surgery in the paper entitled ‘The Safety of Rhytidectomy in the Elderly’. In looking at over 200 patients (divided into over or under age 65) over a three year period by a single surgeon, the complication rates were comparable between the two age groups. (3% vs 2% for major complications, 6% vs 6% for minor complications) Thus indicating that age alone is not an independent risk factor in facelift surgery.

While these studies show that cosmetic surgery is just as safe in the elderly as in the young, it is important to remain vigilant in the planning and workup of the older patient. A good medical workup including laboratory studies and EKG should have been done in the previous six months before the surgery. Specific attention should be paid to their cardiopulmonary history and clearance from their physician. Operative times and the number of procedures should be ‘reasonable’ and not require prolonged recovery times or extended periods of immobilization. Safety and a low rate of complications in the elderly is dependent as much on what their plastic surgeon does as much as their own remarkable tolerance to surgical insult.

Dr. Barry Eppley

Indianapolis, Indiana

October 18th, 2014

Case Study: Otoplasty with Earlobe Reduction


Background: Otoplasty, known as ear reshaping, is a commonly performed cosmetic procedure whose intent is to make the ears less conspicuous. An aesthetically pleasing ear is one which blends into the side of the head and has no feature that makes it an ‘eye catcher’. The best looking ear is really one that is not noticed.

Otoplasty for protruding ears Dr Barry Eppley IndianapolisThe typical cosmetic otoplasty involves the classic setback or ear pinning procedure. This cartilage reshaping technique creates a more pronounced antihelical fold, reduces the prominence of the inner concha or both. This moves the protruding ear back into a less conspicuous position by changing a portion of its shape.

The earlobe is the lone non-cartilaginous structure of the ear. It is often forgotten in otoplasty because it is not part of the cartilage framework. But it can have its own unique set of deformities that if overlooked can mar an otherwise good cartilage reshaping effort. Earlobes can become conspicuous because they stick out or are too long.

Case Study: This 20 year-old female was bothered by the appearance of her ears. As a result she never wore her hair pulled back to reveal them. Her ears showed a deformity consisting of a combination of the upper 1/3  of the ear which stuck out and her earlobes which were unusually long for her age.

Otoplasty with Earlobe Reduction result right side Dr Barry Eppley IndianapolisOtoplasty with Earlobe Reduction result left sideUnder general anesthesia she had an initial cartilage reshaping of the upper ear. Horizontal mattress sutures were placed to make the antihelical fold more prominent and pull back the upper helix through a postauricular incision. The earlobes were then reduced using a helical rim excision technique.

Her ear results showed a much better ear shape from top to bottom. The protruding upper ear was less obvious and the reduction in the vertical length of the earlobes made a huge difference. A shorter and more proportioned earlobe even made her ears look ‘younger’.

Case Highlights:

1) Numerous changes can be made to the ear during an otoplasty procedure besides just pinning the ears back.

2) It is common that repositioning of the protruding earlobe is also done with reshaping of the ear cartilage.

3) Reduction of the long earlobe is usually best done by a helical rim excision technique. It is most commonly done in older patients who may naturally have developed longer earlobes with aging or ear ring wear.

Dr. Barry Eppley

Indianapolis, Indiana

October 17th, 2014

World of Plastic Surgery – Brazil


Plastic Surery in Brazil Dr Barry Eppley Indianapolis Brazil is the largest country in South America and is the fifth largest country in the world. It occupies in land mass almost half of all of South America and has more land than that of the continental United States. (minus Alaska and Hawaii) It is unique in many ways from its Portugese language to being situated along the equator. Of the many things it is known for one of those is the large number of plastic surgery procedures performed within its borders.

While people feel that the U.S. is obsessed with body image and undergoing plastic surgery, it runs a distant second compared to the country of Brazil. According to statistics from the International Society of Aesthetic Plastic Surgery, Brazil has now surpassed the U.S. with the most cosmetic surgeries performed in the world. This is impressive given that the population of Brazil is less than that of the U.S. (203 million vs. 317 million) and with a far less GDP. (2.5 trillion vs 17 trillion) A total of over 1.5 million cosmetic surgeries were done in Brazil, a number that is well over 10% of all elective cosmetic surgeries done in the world. The statistics also show that Brazilian patients are more prone to having actual surgery while the U.S. patients partake of many more non-surgical procedures. (e.g., Botox, injectable fillers and lasers)

Such numbers raise the question as to why Brazil is so profoundly different when it comes to cosmetic surgery. The main reasons are two-fold and synergistic. First, Brazil has the highest number of plastic surgeons per capita than anywhere else in the world. While it struggles to find doctors to service even the most basic needs in remote and poor areas of its vast country, there is a disproportionate number of plastic surgeons. The other reason is that the economy of Brazil has grown considerably and, as such, disposable income has also increased. As part of its unique culture, women are particularly predisposed to spend their disposable resources on improving their appearance. It is so prevalent that having plastic surgery is a status symbol and is something of which to be proud.

thGiven the warmer weather, Brazil is well known for its body contouring procedures such as breast augmentation, breast reductions, liposuction and in particularly buttock enhancements. While breast augmentation is very popular in North America, buttock augmentation is more popular in South America. Brazil is the home and origin of the well known and highly performed Brazilian Butt Lift where fat harvested by liposuction is injected into the buttocks for enlargement.

Dr. Ivo PitanguyBrazil’s most famous contribution to plastic surgery, however, is it own world famous plastic surgeon, Dr. Ivo Pitanguy. Practicing in the Brazilian capital of Rio de Janiero since the 1950s, he established his own clinic where be both operated on patients and trained surgeons. In a public hospital, he created his own ward where he has provided plastic surgery for free for decades. This epitomizes his philosophy that everyone has the right to look better physically.

Dr. Barry Eppley

Indianapolis, Indiana

October 14th, 2014

Fascial Suspension for Pubic Lifts


While there are numerous body areas that can be changed through excisional lifts, particularly after large amounts of weight loss, the most common area treated is that of the waistline. Tummy tucks and body lifts (circumferential lipectomy) make up the most well known and largest surface area removal procedures. Often overlooked (but ultimately not by that of the patient) is the smaller pubic region which lies just below the waistline and may often be hidden by overlying abdominal tissues.

Pubic Lift in a Tummy Tuck oblique view Dr Barry Eppley IndianapolisThe mons pubis is  a skin and fat mound that is located directly above a woman’s pubic bone. This pad of tissue is thought to provide protection of the underlying bones during intercourse. With a predominantly fat composed mound, it is easy to see how it could act as a cushion. But with weight gain (and loss) the fatty pubic mound can sag and remain full of fat that can have a contour that becomes protrusive when what lies above it becomes flattened. It has been well described by patients of how a prominent mons pubis has become ‘unmasked’ by tummy tuck surgery. With a tight and flat horizontal scar line above it, the rounder and more convex pubic mound can stick out further than a flat stomach after tummy tuck surgery.  It is thus well known amongst plastic surgeons to check carefully for the pubic mound contour and incorporate it into the excisional design of the tummy tuck surgery

In the November 2014 issue of the Annals of Plastic Surgery journal, an article appeared entitled Using Superficial Fascial System Suspension for the Management of the Mons Pubis After Massive Weight Loss’. In this paper, fifty (50) patients who underwent a lower body lift had a simultaneous mons pubic lift using a superficial fascial suspension technique. After an average follow-up of nearly 18 months, they were evaluated by before and after pictures as well as a satisfaction survey. Satisfaction of their mons pubic appearance improved significantly. One-third of the patients described the look of their pubic region as very good while half of them described it as good. Eight patients developed prolonged swelling of  the mons pubis and a single patient developed an infected fascia suture which had to be removed.

In the extreme weight loss patient, an unshapely pubic mound always exists even in men. But unlike the fat and more convex mound shape in a more traditional tummy tuck patient, the weight loss patient’s pubic mound is deflated and has substantial skin sag. Thus a significant pubis lift is needed with their tummy tuck/lower body lift and fascial suspension along with skin excision is a logical and stable approach to doing it.

Dr. Barry Eppley

Indianapolis, Indiana

October 12th, 2014

Technical Strategies in Plastic Surgery – Flange Fixation of Displaced Jaw Angle Implants


Jaw Angle Implant Results oblique viewJaw angle augmentation has become an increasingly popular facial implant procedure. While done more in men to enhance an overall weak jawline, it is even done in females who have thin lower faces and lack of any jaw angle width. While historically jaw angle implants only added width to the back part of the jaw, it is now recognized that vertical lengthening of the jaw angles is often needed as well in many patients. This has led to two jaw angle implant types, width only and combined width and vertical lengthening styles.

Regardless of jaw angle implant type, they are usually placed as pairs and their positional symmetry becomes an important part of the aesthetic result. Because the implants are usually smooth (silicone), assuring their position on the bone (and often partly off it to length the angle) is important as any instability can lead to displacement. One simple technique to secure implant position, and the most common one that I use, is single screw fixation. Placed percutaneously, a single 1.5mm screw placed through the implant into just the outer cortex of jaw angle bone is usually sufficient to secure its position.

But in some jaw angle implant cases, particularly those which have suffered implant displacement, an even more secure form of fixation is needed. Jaw angle implant displacement is always superiorly, up and away from its lower desired position over the angle. With healing an enveloping capsule develops around the implant which must be opened or removed to permit it to be positioned in its lower desired position during a revisional procedure This leaves a large upper space into which an unsecured implant can become displaced back into it during the healing phase.

Plate Fixation Jaw Angle Implant Dr Barry Eppley IndianapolisOne absolute secure fixation method for jaw angle implant revision is the ‘flange’ technique using a matrix or grid type fixation plate. By securing the upper end of the metal plate just above the implant with 1.5mms screws, the lower end of the plate overlaps the jaw angle implant essentially pinching against the bone. The upper end of the plate prevents the implant from ever riding up again out of place.

Dr. Barry Eppley

Indianapolis, Indiana

October 11th, 2014

Treatment of Buttock Implant Displacement


Buttock Implants Indianapolis Dr Barry EppleyButtock implant augmentation has historically been plagued by a high rate of complications. Since the intramuscular technique for implant location was introduced in the mid-1990s, the rate of complications has decreased and more natural and long-term results have been obtained. Its advantages over the subfascial location has led to more patients considering the procedure although it is important to realize there are size limitations of the implants that can be placed (300cc to 350ccs) due to the greater restriction of the intramuscular pocket space.

But with the increase in the numbers of such buttock implant surgeries being performed has come a new set of complications unique to the procedure. While incisional dehiscence and seroma are still the most common postoperative problems that can occur, implant displacement out of the intramuscular pocket (herniation) is now being recognized as another potential complication that can occur.

In the October 2014 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Gluteal Implant Displacement: Diagnosis and Treatment’. The purpose of this paper was to describe, classify and standardize the treatment of buttock implant displacement. A cadaver study was done to determine the least intramuscular overlying muscle thickness needed for safe intramuscular dissection. This was shown to be a minimum of 2 cms. Over a three year period, 24 patients were treated for visible buttock implants. Treatment consisted of implant removal, radial capsulotomies, capsular pocket plication, and intramuscular pocket dissection. An anchoring suture was placed at the lateral edge of the muscle incision to prevent muscle rupture during implant insertion. This one-stage approach for implant relocation resulted in only one implant (3%) out of 47 patients that subsequently developed displacement back into the more superficial pocket.

Buttock Implant Surgical Technique Dr Barry Eppley IndianapolisButtock implant complications in the subfascial space (usually seroma) or the intramuscular space (herniation) can be difficult problems to correct. Herniation out of an intramuscular pocket can be associated with implant visibility, pain and recurrent seroma formation. Very much like relocating subglandular breast implants into the submuscular pocket, slipping back into the old pocket is always a possibility. Keeping a limited incisional approach to the intramuscular space is critical and this suture placement is one method to do so. This study shows that successful resolution of buttock implant herniation can be done with a high success rate.

Dr. Barry Eppley

Indianapolis, Indiana

October 10th, 2014

Technical Strategies in Plastic Surgery – Combining Chin Implant and Sliding Genioplasty for Large Chin Augmentations


Chin augmentation can be done by a variety of surgical methods including a chin implant and a sliding genioplasty. Each of these aesthetic chin techniques has a role to play and they have their own advantages and disadvantages. But both have the same limitation…a limit to how much the chin can be horizontally projected. Chin implants are not made with standard thicknesses that are greater than 10 to 12mms. A sliding genioplasty can only be moved as far as the thickness of the bone will allow which can vary between 10mm to 16mms.

The horizontal movements provided by standard chin implants and sliding genioplasties are sufficient for the vast majority of patients with chin/jaw deficiencies. But they can be inadequate for the few patients that have horizontal chin projection deficiencies that exceed 15mm and may be as significant as 25mms.

Sliding Genioplasty and Chin Implant Dr Barry Eppley IndianapolisChin Implant and Sliding Geniplasty in Large Chin Augmentations Dr Barry Eppley IndianapolisCombining a sliding genioplasty with an implant is a novel method to achieve larger amounts of chin projection that I have done for years. Through an intraoral approach, which is needed for a sliding genioplasty, the implant is placed on the chin bone just one would normally do. It does need to be secured into placed by screw fixation otherwise it would easily become displaced. A chin implant with long wings also has the advantage of covering over the bony step-off that often occurs at  the back end of the osteotomy.

Very large chin deficiences can be managed by the creation of a custom implant but combining an implant and a sliding geniplasty may be sufficient in some of these cases. In my experience there has been no higher infection risk when placing an implant on top of a sliding genioplasty than when using a chin implant alone.

Dr. Barry Eppley

Indianapolis, Indiana

October 8th, 2014

Case Study: Tummy Tuck for the Clefted Abdominal Pannus in a Hispanic Female


Background: A tummy tuck is one of the most common and successful body contouring procedures. Between pregnancies and weight loss, the development of loose skin and fat on the abdominal wall is inevitable for many women. This usually appears as a loose overhang on the lower abdomen that hangs like a hammock depending upon its size. This overhang has become known as an abdominal pannus which signifies an apron-like deformity.
One of the unique types of abdominal pannuses has a somewhat familiar look. Any surgery previously done that leaves a vertical scar between the belly button and the pubis (e.g., old style c-section) creates a split down the middle of the pannus. Because a surgical scar often has little fat underneath it, and may even be stuck to the underlying fascia, this results in an indentation which results in a pannus divided into two halves. Patients often refer to this as having a ‘buttocks’ on their front side. The bigger the abdominal pannus is the more likely it appears like a pair of buttocks.
A tummy tuck always creates a low horizontal scar of variable lengths. That is the inevitable trade-off for getting rid of the abdominal pannus. Certain ethnic groups are at higher risk for adverse scar formation, most commonly hyperpigmentation. Intermediate skin pigments, such as Hispanics and Asians, are at such risk as their skin types have well known reactivity to incisions particularly those placed under tension.
Case Study: This 38 year-old Hispanic female wanted a tummy tuck. She had a prior c-section done in Mexico for the delivery of her two children. Between the two pregnancies and some small weight gain, she had developed a ‘butt’ appearance on her lower abdomen with the scar acting as a tether between the two halfs.
Hispanic Tummy Tuck result front viewUnder general anesthesia she had a full tummy tuck done. The large horizontal cut out was done from just above the belly button down to the pubis. Her lower abdominal pannus with its buttocks appearance was completely removed and replaced with a low horizontal scar. Liposuction was done on the flanks on both sides.
Hispanic Tummy Tuck result oblique viewHispanic Tummy Tuck result side viewHer tummy tuck scar developed a small amount of hyperpigmentation but no significant hypertrophy. Over the course of the next year some scar lightening occurred but complete fading to normal color did not occur. This is a common risk in the hispanic tummy tuck patient.
Case Highlights:
1) The clefted abdominal pannus (frontal butt appearance) is caused by a vertical scar between the belly button and the pubis.
2) A full or complete tummy tuck removes the entire deformed abdominal tissue to create a smooth and flat lower abdominal wall.
3) Tummy tuck surgery in Hispanics has a high propensity for hyperpigmented scarring which may require a secondary scar revision.
Dr. Barry Eppley
Indianapolis, Indiana

October 5th, 2014

Case Study: Custom Occipital Implant in a Hair Transplant Patient


Background: A flat back of the head, also known as occipital brachycephaly, is a not uncommon aesthetic skull shape concern. It may occur from the way one laid in utero, how they were positioned as an infant while sleeping or from a genetic tendency based on race. To those so afflicted with this skull shape deformity, they can go to great lengths to camouflage it using hair styles, hats and other concealing maneuvers.

The flat back of the head can be very effectively treated by occipital augmentation using various bone cements and implants. The incisional approach to place these skull augmentation materials can be either high up on the occiput just behind the vertex or low in the occiput just along the nuchal line. There are very few reasons for a long coronal incision with most of today’s implant materials.

Hair Transplant ScarBut one fundamental principle of occipital augmentation is that there has to be enough scalp to accommodate the amount of ‘bone’ expansion required. The scalp tissues are fairly tight and there is a limit as to how much they can stretch with an immediate augmentation. It has been my experience that about 10mm to 15mms of central occipital expansion can be obtained with an immediate augmentation. More than that will require a scalp tissue expander to be placed before attempting implant placement.  The expander only needs to be inflated to about the size of the occipital augmentation needed. Another reason for a first stage scalp expansion are scars and prior scalp tissue loss due to injury or previous surgery.

Case Study: This 41 year-old male had a very flat back of the head that had bothered him for years. He had two prior hair transplant procedures done using a strip harvest method in the low occipital region with a scar that wrapped around  ear to ear. Using computer imaging predictions, it was determined that the amount of augmentation he needed was 15mms at the central occipital region. But given his prior hair transplant harvests his scalp was very tight and it was felt that even this amount of occipital augmentation could not be safely achieved.

Custom Occipital Imp[lant Design Dr Barry Eppley IndianapolisCustom Occipital Implant design thickness Dr Barry Eppley IndianapolisA first stage scalp tissue expander was placed through the central aspect of his hair transplant scar in the low occipital region. It was inflated at home slowly up to 100ccs over six weeks. In the interim, a 3D CT scan was used to create a custom occipital implant with 16mms of thickness in its central aspect.

Custom Occipital Implant with Tissue Expansion Dr Barry Eppley IndianapolisCustom Occipital Implant intraop Dr Barry Eppley IndianapolisA second stage procedure was done through the same occipital incision. The tissue expander was removed and it could be seen that it matched fairly closely to the size of the occipital implant. The custom occipital silicone implant was perforated with a 2mm dermal punch throughout to create multiple perfusion holes. It was inserted through the incision, positioned and the incision closed.

Custom Occipital Implabnt result with Hair Transplant Scars Dr Barry Eppley IndianapolisIt could be seen immediately after surgery that the occipital contour was augmented to a perfectly normal shape from the profile view.

Occipital augmentation for a flat back of the head can be done using a custom implant even in a patient with prior scalp surgery such as a hair transplant. The loss of scalp tissue  does require a prior scalp expansion to prevent the risk of skin necrosis over an implant or to even get the right sizes implant in place.

Case Highlights:

1) Augmentation of a flat back of the head that has had prior tissue excised and scars from hair transplants lacks adequate scalp tissue to safely cover an implant.

2) The scalp tightness caused by previous hair transplant harvests can be overcome through a first stage tissue expansion.

3) A custom occipital implant (2nd stage) can be inserted through a hair transplant harvest scar after initial scalp expansion. (1st stage)

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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