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Plastic Surgery
Dr. Barry Eppley

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

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

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

January 12th, 2014

Secondary Contouring Procedures After Tummy Tuck Surgery

 

Full Tummy Tuck Dr Barry Eppley Indianapolisoblique viewA tummy tuck or abdominoplasty surgery is a very popular and effective body contouring procedure. By removing a full-thickness section of skin and fat from the lower mid-section of varying sizes, the contour of one’s waistline and stomach area can be dramatically changed beyond what diet and exercise can do for most people so afflicted by a lower abdominal roll or a ‘spare tire’.

Provided one does not gain a large amount of weight or become pregnant after a tummy tuck, it is essentially a permanent procedure. Permanency in a tummy tuck is defined as never returning to what one used to look like…which does not mean there may not be some long-term changes to the tummy tuck result. This raises the question of how often do tummy tucks undergo secondary modifications for contour changes. (not revisions for primary tummy tuck problems)

In the January 2014 issue of Plastic and Reconstructive Surgery, article appeared entitled ‘The Incidence and Management of Secondary Abdominoplasty and Secondary Abdominal Contour Surgery’. A retrospective review from a single practice of 562 patients who underwent abdominal contouring procedures (tummy tuck with or without liposuction) over an eight year period. A total of seventy-three of these patients (13%) underwent secondary abdominal contouring procedures although only forty-six of them had records available to be studied.

Secondary Liposuction after Tummy Tuck results front view Dr Barry Eppley IndianapolisMost of these patients (34) had liposuction done whereas twelve (12) had a repeat or full tummy tuck redone. These secondary revisions were done an average of almost five years after the initial tummy tuck. Interestingly those had got liposuction has it done earlier (3 years) than those who had a repeat tummy tuck. (5 years) There was a correlation between a patient’s initial weight (body mass index) prior to the initial tummy tuck and whether they had a secondary tummy tuck or liposuction. Patients with a body mass index greater than 25 kg/m2 required secondary skin removal as well as liposuction while  those with lower body mass indexes (less than 25 kg/m2) needed liposuction only.

It is often said that a tummy tuck is a permanent procedure but the human body, particularly the midsection, continues to undergo some changes as it ages. It should be no surprise, therefore, that some tummy tuck patients will want/need secondary touch-ups or further abdominal contouring efforts. What drives a patient to have a secondary aesthetic procedure is multi-factorial so putting an exact number to the incidence is far from precise.

But suffice it to say, as this paper illustrates, tummy tuck results can and do change and the most common of these changes is the accumulation of fat over time. Thickness of the trunk and abdominal skin flaps can occur which is subsequently treated by liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

January 11th, 2014

Saline Injection Trials for Facial Implants

 

Facial augmentation can be done by either temporary injectable fillers into the soft tissues or permanent implants placed down on the bone. Such materials causing a change in the external shape of the face in the area treated but its exact change can not be precisely predicted. While computer imaging can try to create the change caused by these facial volumizing procedures, it is still an estimate.

When it comes to the placement of facial implants, there is much more of a commitment due to the surgical process. Some patients may feel more comfortable having a test or trial volumization procedure done prior to the actual surgery. While the most common method for a facial implant trial would be any of the commonly used injectable fillers, for a few select patients the length of their duration may be too long. (months)

Saline Solution for Facial Injection Dr Barry Eppley IndianapolisAnother type of injectable filler that can be used that is very short-term (hours) is that of saline. Saline injections, which are a mixture of water and salt, are used for variety of medical purposes. The most common use for a saline mixture is for intravenous infusions for hydration, mixing it with medicines to make an injectable solution and as over the  counter nasal sprays and contact lens cleaner. Additional but less common uses for saline injections are for spider vein treatments, acne scars and some very unusual types of body modifications.

Saline is often called Normal Saline (NS) or isotonic saline as a solution of 0.9% of sodium chloride (NaCL) created by dissolving 9 grams of NaCL in 1000ml of water. (for those who like a kitchen analogy that would be 1.6 teaspoons of salt) Normal saline contains 154mEqL of Na+ and Cl- and has only a slightly higher degree of osmolarity than blood. A 0.9% concentration is often presumed to be the sodium concentration in human blood which is inaccurate  since it is closer to 0.6%.

Saline can be injected very safely into the face in any location that would be typically augmented for increased volume. By using a microcannula technique it can be done painlessly. However, saline solutions have some degree of acidity (ph of 5) and may be associated with sight burning on injection. This can be remedied by adding a touch of sodium bicarbonate or using a more ph-balanced solution like Lactated Ringer’s. (LR)  The volumes adds to create a facial effect are greater than what one experience with traditional injectable fillers due to their higher viscosity. Saline or LR is absorbed quite quickly and will usually be completely gone in less than four hours.

Saline Facial Injections Dr Barry Eppley IndianapolisThe purpose of saline injections is to give the patient an immediate facial volumizing effect so they can see if augmentation of a facial area is aesthetically beneficial. When requested by a potential facial implant patient, it can make the patient feel more secure about a surgical decision for implants. This is particularly true in cheek and orbital rims implants where insecurity about that area of facial augmentation is often most uncertain.

Dr. Barry Eppley

Indianapolis, Indiana

January 11th, 2014

Long-Term Hairline Stability in Pretrichial Browlifts

 

When it comes to forehead rejuvenation a variety of browlifting strategies exist. Three of the browlifting methods use a superior or scalp incisional access to do the procedure. The most popular of these is the endoscopic technique which uses a few small scalp incisions and an epicranial tissue shift to create its brow elevation effect. It is popular because of a lack of significant incisional lengths even though it does also result in some forehead lengthening.

Pretrichial Open Browlift Scar Dr Barry Eppley IndianapolisA very effective but less popular browlift method is the pretrichial or hairline technique. Making an irregular incision along the frontal hairline, the brows are lifted but without elongating the forehead. While this does place a scar along the frontal hairline, in the properly selected patient with good frontal hairline density, the scar can heal remarkably well and has rarely been a concern in my experience. There is always the understandable concern, however, if whether this incision negatively affects hair growth after healing and in the long-term. (does hair loss occur along the incision)

In the January 2013 issue of Plastic and Reconstructive Surgery, an article was printed entitled ‘Cessation of Hairline Recession following Open Forehead Rejuvenation’. Over a 15 year period, 31 patients had browlifts done using either the endoscopic (17) or open pretrichial incision (14) approaches. Measured photographs of eyebrow to hairline distances were done at 1 and greater than 8 years after surgery and compared to other cosmetic surgery patients who did not have forehead rejuvenation. Their results showed that over the long-term only the pretrichial group had a stable or improved hairline position without any signs of recession. No separation was seen between the scar and the hairline in the pretrichial incision patients.

This study is very relevant to not only pretrichial browlifts but other procedures that use incisions along the hairline such as a hairline lowering/advancement surgery for forehead reduction. Whether it is a woman or a man (but particularly in men), there is always the concern that hair loss may occur along the incision from surgical trauma or that long-term hairline recession may occur. These findings in this paper allay those concerns and suggest that the incision may have some protective effect in the long-term for follicular preservation…and intriguing but as of yet unexplainable biologic effect.

Dr. Barry Eppley

Indianapolis, Indiana

January 9th, 2014

Sientra Textured Silicone Breast Implant Capsular Contracture Warranty

 

Of the numerous complications that can occur in breast augmentation, capsular contracture is the most vexing of them all. The formation of excessive circumferential scar formation around the implant can be problematic in terms of the look and feel of the breast with potential hardness and shape distortion. The reason for capsular contracture  in many patients is usually unknown. But when it occurs and it is significant, it will require surgery for improvement/correction of the affected breast.

All breast implant manufacturers have nearly identical warranties in the advent of one specific complication, device failure. (rupture)  This applies both to lifelong implant replacement and a ten year reimbursement for the surgery to replace it from the date of implantation. This applies to saline, smooth round silicone and textured silicone shaped breast implants.

Sientra Breast Implant Capsular Contracture Warranty Program Dr Barry Eppley IndianapolisBut a new level of  warranty has now emerged from one of the manufacturers, Sientra, that covers the complication of capsular contracture should it occur. Known as C3 (CapConCare), it is the industry’s first capsular contracture care program. It covers primary breast augmentation patients using the TRUE texture breast implants  who have developed Grade III and Grade IV capsular contracture problems within two years after the initial surgery. It only applies to surgery performed by board-certified plastic surgeons with implants placed beginning November 1, 2013.

Sientra Textured Shaped Breast Implants Dr Barry EppleyThe genesis of this warranty undoubtably has its basis in the knowledge of how well Sientra’s textured silicone breast implants have performed. In a large U.S. clinical trial  encompassing 4,312 primary breast augmentation patients followed over five years, there was a 0% incidence of gel fracture, a 0.4% rupture rate and a 3.9% capsular contracture rate.

Dr. Barry Eppley

Indianapolis, Indiana

January 7th, 2014

Plastic Surgery Wisdom: Is The Scar Worth it?

 

Plastic Surgery Wisdom Dr Barry Eppley IndianapolisAlmost all plastic surgery operations create scars. Sometimes the scar is hidden and a near irrelevant issue. Other times the scar is very visible and is a significant consideration as to whether one wants the operation or not. But there are cases where  the scar is ‘equivocal’. Maybe the scar trade 0ff is worth it and maybe it isn’t. How does one choose? The best method to judge whether the aesthetic benefits of any operation vs the scar it takes to do it…is to assume the worse from a scar standpoint. Meaning if you look at pictures of the scar(s) that result from the operation and have an immediate response that it is a trade-off worth making, then it is the right operation for you. If that scar seems worse than the aesthetic issue you have, and your gut reaction is not positive, then it is not the right operation for you. You always assume the worst for scars since one never knows how well they will work. You don’t make the decision on the best scar possible but rather the worse case scenario. In that way you will never make the wrong decision.

‘The Acceptance of Scars in Plastic Surgery Is Not A Logical One…It Is An Emotional Decision’

Dr. Barry Eppley

Indiamapolis, Indiana

January 6th, 2014

Preventing Buttock Implant Complications By Proper Size Selection

 

Buttock Plastic Surgery Indianapolis Dr Barry EppleyButtock augmentation is one of the most in demand body contouring procedures today. While ten years ago it was infrequently requested compared to breast augmentation for example, it has increased over ten-fold since then. Such an increase in buttock augmentation has been driven by many factors including the celebrity appeal. (Jennifer Lopex, the Kardahasians and Nicki Minaj to name the most conspicous) But the most important contributor to buttock augmentation interest is that of fat grafting. Using your own natural tissue and getting a liposuction benefit from the donor site makes the decision for gluteal enhancement an easier one.

While fat grafting to the buttocks is the most common and popular way to create a bigger derrière, it is not for everyone. The unpredictability of fat graft volume retention and the lack of adequate donor fat make the Brazilian Butt Lift (BBL) not possible for some patients. This leaves the use of buttock implants as the alternative choice.

Implants predate the use of fat for buttock augmentation by over a decade. With the predominance and the more recent appeal of fat grafting, implants have been associated with exaggerated reports of complications. While any implant is going to be associated with more complications than a fat graft, there complications are actually no higher than that of breast implants.

In the April 2013 issue of Plastic and Reconstructive Surgery, an article entitled ‘ Buttock Augmentation with Silicone Implants: A Multicenter Survery Review of 2,226 Patients‘. In this paper, over 2,200 cases of buttock augmentation with silicone implants were reviewed from nearly 20 surgeons. Their results showed a 38% complication rate that was anything from an incisional separation to an implant infection. The most common complication was a near 8% incidence of incisional separation. The most dreaded complication was buttock implant removal for any reason which was just under 4%. The rate of buttock implant revision was 5%, excessive implant palpability at 3.5% and prolonged pain at 5%. Minor infection not requiring implant removal was just under 4% and major infection requiring implant removal was at 1.7%.

One important aspect of this study was that it did not separate complications from subfascial vs intramuscular buttock implant placement. To experienced buttock implant surgeons, this location difference is felt to play a critical role in the incidence of buttock implant complications…very similar to that of breast implants.

Buttock Implants Augmentation Dr Barry Eppley IndianapolisWhen you look at the #1 complication of buttock implants, incisional separation, the major factors contributing to this problem are implant size and incisional closure techniques. If the buttock pocket is not big enough for the implant placed, it will put excessive pressure on the incisional closure. It is felt that any implant volume greater than 300 to 3530cc for intramuscular placement is excessive. When it comes to subfascial  placement the implant volume can be higher but still must remain in proportion to the enveloping soft tissue envelope.

One of the dilemmas in buttock augmentation by implants is that the buttock size many patients want exceeds that of what their soft tissue pocket can accommodate. This ‘forces’ many surgeons to potentially place a larger implant than what they should. This requires good presurgical education to control patient expectations. Some patients have to realize that some permanent volume increase without complications is better than an ideal buttock volume with complications.

When you look at the complication rates between buttock and breast implants, based on three year from installation data, one can see that they are not that different. What is different is the recovery period because you do not have to sit on your breast implants nor do they have a role in walking and bending over.

Dr. Barry Eppley

Indianapolis, Indiana

January 6th, 2014

Spot Cranioplasty for Skull Dents and Dimples

 

The skull has a wide variability of external shapes and no two people have exactly the same looking head. But most of the time these skull shapes share one consistent feature…they are usually smooth. The outer bony surface has a relatively smooth convex surface which translates into a smooth feeling scalp on the outside. This is seen in most image of skulls of either actual people or mock skull models.

Phrenology Dr Barry Eppley IndianapolisBut the reality is that not every skull is completely smooth and many people can feel some degree of small lumps and bumps on their skull. This is well illustrated in the 19th century practice of the pseudoscience of Phrenology in which skull contour irregularities purportedly translated into a person’s psychological attributes. While Phrenology has long been discredited as having any relevance to a person’s psychological make-up, some of a skull’s dents and dimples are aesthetically bothersome to some people.

Why certain skull irregularities occur is not known in all cases. Some people have skull indentations from a history of neurosurgery or trauma but the vast majority of skull dents and dimples have no known identifiable cause. A very common reason that they exist is because of how the skull forms. The fusing of the skull plates after birth creates the possibility of indentations to occur at these fusion points, most commonly at the anterior and posterior fontanelles. The bone formed here may be thinner and form a very well defined ‘dimple’. But the skull fusion issue does not explain all skull dents or dimples as many lie beyond the fusion location of the skull plates.

Injectable Cranioplasty for Skull Dimples (Skull Dimpleplasty) Dr Barry Eppley IndianapolisCorrection of small skull irregularities can be done through a very limited incisional approach that I have coined as a ‘spot cranioplasty’. While it may look like an injectable cranioplasty technique when seeing pictures of it being done, it is only because the bone cement is delivered to the defect site that way. (injected through a syringe) It does requires a small incision, usually 1 to 1.5cms in length, as a subperiosteal dissection needs to be done prior to placing the material. This is a critical step and one that can only be done through an open approach. All of the scalp soft tissues soft tissues need to be elevated off of the bone to make a pocket for the cranioplasty material. The tissues need to be elevated way around the skull contour defect so that the bone cement can be introduced and fill the concavity up to the level of the surrounding normal skull bone.

I have tried every available cranioplasty material for this approach and find that PMMA has the easiest and most reliable handling characteristics. Because of its putty-like consistency and flow characteristics as it transitions into a solid polymer, it can be introduced through a small incision down to the bone. Depending upon the size of the dent or simple, 1 to 3ccs of material is usually all that is needed to fill it. While the amount of material to place is an artistic judgment, it is important to realize that it is better to underfill than overfill. You do not want to convert a skull dimple into a skull bump. The shape of the PMMA material introduced is then shaped by pressing from the outer scalp to smooth it down and around the defects as it cures and gets hard. The edges of the material are then checked with an instrument through the incision for smoothness.

Spot cranioplasty is the simplest type of skull reshaping procedure for small indentations or depressions of the skull’s surface. It can be done through an incision of minimal length. While a variety of cranioplasty materials can be used, PMMA offers the most reliable method of passing through a small incision and being able to be shaped by external scalp manipulation.

Dr. Barry Eppley

Indianapolis, Indiana

 

January 6th, 2014

Botox Injections for Keloid Scars

 

Keloid Scar Surgery Dr Barry Eppley IndianapolisKeloids represent the extreme of scar problems. As a tissue overgrowth response to an injury, and often progressive and unremitting, keloids are a true pathologic scar problem. Besides being an overly obvious scar problem, it is also highly refractory to conventional scar therapies. While many strategies have been used for difficult keloids after excision (e.g., steroid injections, radiation treatments), there still remains a very high recurrence rate. There remains a need to for new and novel approaches to see if lower recurrence can be achieved.

In the Summer 2013 issue of the Canadian Journal of Plastic Surgery, an article was published entitled ‘Eradication of Keloids: Surgical Excision Followed By A Single Injection of Intralesional 5-Fluorouracil and Botulinum Toxin’. This study involved eighty (80) patients with keloids of at least one-years’ duration. Following total surgical excision of the keloid, a single dose of 5-fluorouracil (5FU) was injected into the edges of the healing wound on postoperative day nine (9) together with botulinum toxin.

The concentration of 5-fluorouracil used was 50 mg/mL and approximately 0.4 mL was infiltrated per cm of wound tissue, with the total dose <500 mg. The concentration of botulinum toxin was 50 IU/mL with the total dose <140 IU. Patients were followed-up to two years and a recurrence rate of 3.75% was found.

The present study shows a very low recurrence rate by keloid scar standards that is comparable to other studies with post-excision radiation treatments. One has to assume that it is the Botox that has a significant pharmacologic effect as 5FU injections alone would not have such a low recurrence rate.

Botox Injections for KeloidsSince Botox has a known effect as a muscle weakener/paralyzer, how then does it work on scars? Several clinical studies and reviews have been done on the effects of Botox injections on scars. Besides the obvious benefit of preventing muscle pulling on the edges of a fresh wound or scar (which is really only a consideration in certain types of facial scars), its potential benefits are largely conjecture. Some have hypothesized that it inhibits fibroblast proliferation or the action of myofibroblasts, which makes theoretical sense, but that has never been scientifically proven or verified.

This is a fairly large clinical series of keloid treatments and would thus indicate that there  is merit to the injection of Botox after their excision. The mechanism of action remains speculative but its use is certainly more convenient and less costly than post-excision radiation treatments.

Dr. Barry Eppley

Indianapolis, Indiana

January 5th, 2014

Injectable Fillers for Rhinoplasty Contour Deformities

 

Rhinoplasty is a well known reshaping operation of the nose with a long history and a large number of techniques to accomplish these changes. Despite the many rhinoplasty techniques and a lot of experience in performing them, there is always the risk that some irregularity or asymmetry will develop after surgery. While many of these post-rhinoplasty asymmetries and irregularities may be ideally treated surgically with cartilage adjustments or grafting, this presents the need for a return trip to the operating room, anesthesia and additional expenses.

Injectable Fillers in the Nose Dr Barry Eppley IndianapolisOne method to easily treat volume deficient rhinoplasty deformities are injectable fillers. They produce immediate results at a low cost. While many such injectable fillers exist, the hyaluronic acid (HA) fillers are the most popular and safest to inject into the nose. The interesting questions about their use are how successful are they and how long do they persist?

In the May 2013 issue of the European Journal of Plastic Surgery, an article was published entitled ‘Use of Hyaluronic Acid in the Correction of Contour Asymmetries Following Rhinoplasty’. Over a 6 month period, a total of 12 patients who had contour problems after rhinoplasty were treated. A hyaluronic acid filler was injected from subcutaneous to subperiosteal/subperichondrial. The results were evaluated on a 1 to 10 satisfaction scale for up to one year after the injections.  No side effects were reported. All patients were satisfied with the filling procedure even though they were aware of the non-permanent nature of the procedure.

It is no surprise that the use of a hyaluronic filler in the nose meet with a high satisfaction rate and, in this report, no complications. They key is to use low volumes and spot application of the filler. The riskest area of injection into the nose is the tip and large volumes should be avoided. (although they would rarely be needed anyway)

In my experience, most of the deformities after rhinoplasty are relatively small and discrete. And unlike when placed in the lips or nasolabial folds, the lack of any motion or facial expression across the nose allows them to last beyond what one would expect in other more typical facial application areas.

Dr. Barry Eppley

Indianapolis, Indiana

January 5th, 2014

Ear Pointing and Ear Elf Surgery

 

It is not rare that a patient will request to see if some face or body feature they have can be changed to look more like that possessed by a certain celebrity. Whether it be a nose, jawline, breasts or buttocks, the shape of the famous has always motivated others to seek the same. But in almost all these cases, the desire has been to achieve known shape and proportions of body features that are variations along anatomical features that can naturally occur.

Ear Pointing Dr Barry Eppley IndianapolisBut unusual face and body changes do get requested and occasionally done. One such example is the procedure known as ear pointing or elf ear surgery. The description alone tells you exactly what is being done. The desire for this procedure undoubtably has its history in Star Trek and the character Spock. But the more recent movie series of Lord of the Rings and the Hobbit movies puts only display a much larger number of characters with different ear shapes, almost all of them with ear points of various elongations.

Ear Elf Surgery Dr Barry Eppley IndianapolisThis has driven a few fans and devotees of the films to actually having their ears reshaped. One such fan who is a young model who recently underwent the procedure and chronicled her experience in an online video on YouTube which can be found under Elf Ear surgery. While many would understandably question the motivation for such an unusual ear modification, that decision and explanation is best left for the patient to answer. What is more anatomically relevant is can it really be done and, if so, how?

Ear Anatomy Dr Barry Eppley IndianapolisThe normal ear is formed by islands of cartilage (six to be exact) that come together to form a complex series of raised ridges and valleys. One of these prominent cartilage ridges is the one that rings around the upper two-thirds of the ear known as the outer helix. It essentially goes a long way in creating the recognizable ear shape of humans. The top of the outer helix forms an upper semicircle that surrounds the upper 1/3 of the ear. Inside the outer helix is the antihelix which represents a folding of the conchal cartilage and has a similar prominence to the outer helix. This is what is created in the classic ear pinning surgery for prominent ears. As the antihelical fold comes into the top of the ear it branches about two-thirds of the way along its course to form the broad fold of the superior (posterior) antihelical crus and the more sharply folded inferior (anterior) crus. Between the superior and inferior crus is the indentation known as the triangular fossa.

Ear pointing is done by taking a small wedge of skin and cartilage from the upper ear. This is like removing a slice of pie that contains the outer helix and potentially some portion of the superior crus. This triangular excision needs to be done closer to the junction of the upper and ascending outer helix so that when it is sutured together it creates a well defined point. In elf ear surgery, a much larger wedge of ear tissue is removed that effectively removes most of the superior and inferior crus so that the approximation effectively flattens the upper outer helix.

Like all ear reconstruction and reshaping surgery, it requires an understanding of how to manipulate the natural ear cartilages to obtain the desired shape. Ear pointing and ear elf surgery illustrate this point to the extreme.

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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