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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.

April 21st, 2014

The Success of Temporal Migraine Headache Surgery

 

Certain types of migraine headaches have been attributed to compression of the extracranial portions of the trigeminal nerves. One of the four main types of peripheral compression migraines are temporal-based which result from the temporal muscle squeezing the zygomaticotemporal branch of the trigeminal nerve. (there could also be a concomitant effect of a tight fascial opening as well) It is where the nerve passes through the muscle and fascia on its way to supply the overlying skin in the temporal region as to where it is affected. This is at an approximate point in the temporal skin between the corner of the eye and the eyebrow.

Decompression of this affected nerve for temporal migraines is really an avulsion technique. Through an endoscopic approach, the nerve is identified as it comes through the deep temporal fascia, grasped and pulled like a small piece spaghetti. There is no harm in eliminating this nerve as it only supplies a small area of skin with feeling in the temporal region. As the nerve is avulsed, its most proximal end retracts into the temporal muscle under the fascia which is helpful for prevention of potentially painful neuromas. While  this technique is uncomplicated to perform, how success is it in reducing temporal migraines.

In the April 2014 issue of the journal Plastic and Reconstructive Surgery, a study entitled ‘In-Depth Review of Symptoms, Triggers and Treatment of Temporal Migraine Headaches (Site II)’ was published which examines this very question. Over a ten year period, a total of 246 patients who underwent temporal migraine decompression surgery were assessed to determine the success of the procedure. It was determined that 85% of the patients had at least a 50% improvement in their headache symptoms at one year after surgery. Over half (55%) reported a complete elimination of their headache symptoms.

This study supports the benefits of zygomaticotemporal nerve avulsion to reduce the severity and frequency of temporal-triggered migraine headaches.  Despite its relatively high success rates for headache reduction, it does not solve every patient’s symptoms. There may be other contributing factors to migraine headaches such as the auriculotemporal nerve and the anterior branch of the superficial temporal artery. In those patients who have minimal improvement, these sites may be considered for secondary treatment.

The ideal candidates for temporal migraine surgery are those that have very specific symptoms that are be traced to the topographic location of the zygomaticotemporal nerve location. For those that can specifically point to the exact temporal location, the use of preoperative Botox testing can be bypassed.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2014

Plastic Surgery Product Review: Living Proof Neotensil Under Eye Treatment

 

Under eye bags and wrinkles are a major aesthetic concern for most people as they age. No matter how many creams and topical treatments one may try, they are hard to improve without actual surgery for more advanced under eye aging. While lower blepharoplasty techniques are the definitive treatment, surgery involves recovery and does not produce an immediate effect.

Neotensil Undereye Treatment Dr barry EppleyNow along comes the Neotensil Under Eye reshaping product which is neither a surgical procedure, laser or cosmeceutical treatment. It is an clever and innovative use of a polymer film that can be applied to temporarily tighten and reshape the under eye area. The name is actually an acronym that after Neo stands for transforming (T), elastic (E), noninvasive (N), supportive (S), invisible (I) and layer. (L)

Neotensil Living Proof Dr Barry Eppley IndianapolisNeotensil uses a proprietary cross-linking polymer film technology which is applied  in a two-step process. Initially a base is mixed with an activator and then it is applied with a special tool. Once it dries, it creates a clear and flexible membrane on top of the under eye skin that tightens and smooths as the polymer contracts on setting. A clinical study showed that 99% of patients showed visible improvement in compressing and changing the shape of the under eye area. Many patients in the study (70%) showed substantial improvement with a change in at least two grades in an aesthetic improvement scale. Its effects are temporary and last from 16 to 24 hours.

Under the marketing name Living Proof, Neotensil is distributed through Valeant Pharmaceuticals as a kit. It retails for $500 and has enough product for 50 applications. This factors into $10 a use. While most people will probably not use it as an everyday cosmetic treatment, it is a great product for special events or a night out on the town for those who want to temporarily improve that tired under eye look.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2014

Cartilage Graft and Implant Techniques in Asian Rhinoplasty

 

Rhinoplasty of the Asian nose requires almost completely different techniques than that of the Caucasian nose. In the Caucasian nose it is usually about reduction and rearrangement of structures, while in the Asian nose it is about augmentation and extension of structures. The anatomy of the Asian nose is characterized by a weak and underdeveloped bone and cartilage support structure with usually a thicker overlying soft tissue layer. This creates an aesthetically short nose with poor tip projection and wider flared nostrils.

While augmentation of the bridge of the Asian nose  is often done by a silicone or PTFE-coated silicone implant, the management of the tip is a different matter. Attempting to extend the silicone implant in an L-shaped to increase nasal tip projection and a downward tip rotation is fraught with long-term problems due to the pressure of the implant on the overlying tip skin. As a result, nasal tip management should be done by using the patient’s own cartilage. However, donor cartilage from the septum in Asians is usually in short supply for the amount needed to extend and support the nasal tip.

The best method to control tip projection and rotation is through the use of septal extension and tip onlay grafts. But the paucity of septal cartilage requires an additional donor source for both types of grafts and this is the ear. The septum is the donor site for the septal extension graft(s) and the ear is the donor site for the cap or infralobular tip grafts. These two types of grafts combined with defatting of the underside of the dome skin and dome suture plication complete the nasal tip reshaping.

Septal extension grafts in the Asian nose can usually extend up to 6mms or more after the lower alar cartilages and its attached soft tissues are released and stretched. The key maneuver is in how to fix the extension grafts onto the caudal end of the septum. A single graft can be overlapped onto the septum and brought forward. But the most stable method is to create a V-shaped graft construct. One extension graft is applied at the top of the causal septum in a horizontal direction and secured on one side of the septum. The other graft is applied between the tip of the initial extension down at 45 degrees and fixed to a lower position on the septum on its opposite side.  A recent study has shown/suggested that this septal extension construct is biomechanically more stable to resist the pullback of the stretched overlying tissues.

Once the nasal tip has been grafted and stabilized, the dorsal augmentation is then done. If the patient is not amenable to a rib graft for bridge augmentation, a silicone implant must be used. The thickness and length of the implant is determined by taking a ruler and placing it between the midpoint of the glabella and resting it on the nasal tip. The underlying space between the ruler and the nasal skin determines the graft shape and length. This is ideally measured and carved as the first part of the rhinoplasty procedure and is done before the nose is even opened. This allows for an accurate graft sizing since the tissues are not distorted.

My preferred technique in Asian rhinoplasty tip management is a dual cartilage graft approach with septal extension and onlay tip augmentation. Dorsal augmentation can be managed by  a rib graft implant, which is the patient’s choice.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2014

Comparing Botox, Dysport and Xeomin Injectable Facial Neuromuscular Modulators

 

The announcement this month that Johnson & Johnson (J & J) has pulled any further development of their aesthetic neuromuscular modulator PurTox was a surprise. It was certain several years ago that a fourth injectable drug would soon be on the market to compete with the big three, Botox, Dysport and Xeomin. But it now appears that these three cosmetic drugs will only have only to compete amongst themselves for some time into the foreseeable future.

Botox Facial Wrinkle Injections Dr Barry Eppley IndianapolisIt has now been three years since the last of the big three (Xeomin) was approved. And while there has been some minor new FDA approvals for indications that were already widely done off-label anyway (crow’s feet), the number of men and women seeking this injectable cosmetic treatment continues to grow. Having multiple products to treat unwanted facial lines and wrinkles has helped create awareness and grow the market. These drugs today are as accepted as capuccinos and are done almost just as much. To some degree, Botox and his competitors have very much become commodities where the lowest cost per unit often sways what provider/location that a patient will go to.

This raises the question of how do these drugs differ and, what advantages if any, do any of them offer over the others? What all three drugs share is that they are FDA-approved Type A botulinum toxins. They work exactly the same through the same mechanism of molecular action and all have the same type of heavy chain receptor. While Dysport and Xeomin have a little shorter onset (1 to 2 days), they last the same amount of time as Botox having a duration of action of between 3 and 4 months after injection.

Dysport Indianapolis Dr Barry EppleyThey do differ significantly, however, in their dosing and methods of storage. The dosing of Dysport is very different from that of Botox or Xeomin. This makes it difficult to compare Dysport to the other two in clinical studies. While the biologic activity is the same for Botox and Xeomin, it is quite different for Dysport and there is no standard dose conversion. While all three must be reconstituted on the day of administration, Xeomin does not require refrigeration which makes it more portable and not prone to be accidentally left out of cold storage after a treatment.

From a marketing and public awareness standpoint, Botox is the dominant force occupying close to 80% of the market. It is the ‘Coke’ of the injectable neuromuscular modulators, the most studied and also the most expensive. Dysport and Xeomin are the ‘Pepsi’ and ‘Seven-Up’ by comparison and are still trying to gain market share. As a result they are priced under that of Botox and is there only real method of improving their small market share given that they have no other advantages.

Xeomin Indianapolis Dr Barry Eppley IndianapolisSome small claimed advantages over Botox for Dysport is that it has wider zone of diffusion from the injection site. This may be an advantage in the bigger muscles areas of the frontalis muscle of the forehead and the orbicularis muscle of the crow’s feet area. But would be a disadvantage in a discrete muscular area like the glabella which is also the number one area for all aesthetic neuromuscular injections. Xeomin claims a less risk of allergic reaction than with Botox because it does not contain hemagglutin and non-hemagglutin complexing proteins. While this may be theoretically true, the incidence of allergic reactions to Botox is so insignificant after over twenty years of clinical use that this advantage is meaningless.

While there are other aesthetic injectable neuromuscular drugs under development, none of them seem to have any major advantages over the big three that are available now. Every patient would like them to last longer (or be permanent) and cost less but that does not appear to be likely for as far as one can see into the future. The one promising approach is that of a topical botulinum type A gel of which several companies have ongoing clinical trials. Avoiding needle sticks could be the one advantage a new product could have that would help shakeup the market as we know it now.

Dr. Barry Eppley

Indianapolis, Indiana

April 20th, 2014

Plastic Surgery Wisdom: Achieving Natural Results

 

Plastic Surgery Wisdom Dr Barry Eppley IndianapolisMost everyone that considers some cosmetic plastic surgery procedure is interested in a natural result. While the concept of a natural looking result is open to wide interpretation, it usually refers to a procedure that is not overdone. Being overdone in plastic surgery often refers to cosmetic operations(s) that may have been performed in an aggressive manner. This could refer to the facelift that was pulled too tight, the breast implants that were too big or the browlift that was elevated too high, to name a few examples. While every patient wants the most ‘bang for their buck’, more of a physical change may not always be better. It becomes critical, therefore, for every patient to relay in as much detail as possible to their plastic surgeon as to the exact type of change they are seeking. Since so many patients use the term ‘natural’ to describe what they want, one had better be sure what the plastic surgeon sees as natural and how an unnatural outcome is going to be prevented. Don’t assume a natural looking result occurs ‘naturally’.

Natural Results in Plastic Surgery Needs To Be Defined Before The Operation

Dr. Barry Eppley

Indianapolis, Indiana

April 19th, 2014

The Benefits of Fat Grafting in Facial Reshaping Surgery

 

Facial skeletal surgery, what I often call facial structural surgery, offers many options for changing the form of the face. From jaw repositioning to bone reshaping to implants, significant foundational changes can be done. While much of facial skeletal surgery is done in the young (under age 45), this does exclude older patients as well. But no matter how the facial bones are changed or at what age, the final result is heavily influenced by how the overlying soft tissues settle and heal over the underlying bone changes.

While bone modifications can make a significant difference in the external facial shape, they can not always make every desired facial improvement. Some facial changes require a combination of both bone and soft tissue augmentation to get the desired effect.This is particularly true in cases of facial asymmetry and areas of differing soft tissue thicknesses.

One of the soft tissue effects of facial skeletal surgeries in some patients is that the overlying soft tissues can thin after surgery. This is almost exclusively the result of subcutaneous fat atrophy from the trauma and swelling of the surgery. This is seen in cases from facial fracture repair to orthognathic surgery.

Facial Fat Injections for Linear Scleroderma Dr Barry Eppley IndianapolisIn the April 2014 issue of Aesthetic Plastic Surgery Journal, an article was published entitled ‘Application of Fat Grafting in Facial Aesthetic Skeletal Surgery’. In this report, the authors describe a series of cases in which fat grafting was done as either done at the time of facial skeletal surgery or was performed as a secondary procedure afterward. In twenty one (21) patients, thirty-seven fat grafting procedures were done. The type of facial skeletal surgery included sliding genioplasties, facial bone reshaping and for facial asymmetry improvement. The fat injections were intended to improve asymmetries and irregularities over reshaped/repositioned bone or implants. Of the 37 procedures, four (11%) complications occurred of which most were infections.

Fat grafting today has many versatile uses in facial surgery. While often perceived for aesthetic facial augmentation only, it has many reconstructive uses as well. It is the missing link in facial skeletal surgery to make contour changes that may remain deficient despite underlying bone modifications. For example, I recently treated a middle-aged male patient with severe facial lipoatrophy from antiviral medication with temporal and combined malar-submalar implants. But as was suspected before surgery, the area between the temples and the cheeks across the zygomatic arch remained deficient, creating an ‘hourglass deformity’ This was filled in with fat injections as well as around the lower end of the cheek implants to give a confluent facial contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

April 14th, 2014

The Impact of Pregnancy On A Tummy Tuck

 

Tummy tuck surgery is one of the most commonly requested and satisfying of all the body contouring procedures. While it is has many potential issues including scar length and recovery, it is often the only way to significantly change the waistline and abdominal shape for many women. Some women make valiant efforts with diet and exercise regimens but find that they eventually ‘hit the wall’ and then appear for a tummy tuck consultation.

Pregnant womanA tummy tuck works because it removes excess skin and fat from around the waistline, resulting in a flatter abdomen and a less round waistline. But because of the scar and the muscle tightening, it is always a good question how a future pregnancy may affect the result. Because a tummy tuck is a pure cosmetic procedure that only affects what lies outside the abdominal muscle layer, it has no effect on the ability to get pregnant. It is always advised to wait to have a tummy tuck after one is certain they are done having children. But it is not rare to have a woman get pregnant after having a tummy tuck even though they may be certain beforehand that their child creation days are over.

So it is not a question of whether one can get pregnant after having a tummy tuck but whether the pregnancy will affect the positive changes that the tummy tuck created. While every woman is different, suffice it to say that pregnancy following a tummy tuck will adversely affect some of its cosmetic benefits. The skin and the muscles will expand with the pregnancy, it is just a question of how much and whether the tissues have good recoil (shrink back down) afterwards.

One common observation that women report is that becoming pregnant again after a tummy tuck results in a much later show than in their earlier pregnancies. This would be expected since both the overlying skin and the underlying muscles are tighter than ever before. But the expanding baby will, by slow and continuous pressure (like a tissue expander), stretch out to accommodate its need for space. This will create some muscle and skin looseness that does effect the tummy tuck results after delivery. Depending upon how large one gets, most post-pregnancy tummy tucks will desire to have some retightening or ‘touch-ups’ to regain their pre-pregnancy tummy tuck form. Often this may be more of a mini tummy tuck approach or even simple skin removal along the old scar line.

The timing for a secondary tummy tuck after pregnancy would be the same as with an initial tummy tuck after pregnancy. Wait until all the tissues have shrunken down and the baby fat is lost. This is usually at least three months after delivery and six months is more ideal for some women.

In a contrarian approach, I have done four cases of tummy tuck revisions at the same time of delivery as requested by the patients. Their point was that they were already on the operating room table and knew that they would have some skin excess. They all were going to have c-sections through their old tummy tuck scar anyway. This seemed like a good time to them to address any abdominal excesses.  While you can not tighten the abdominal muscles due to the size of the uterus, residual abdominal skin can be safely removed as part of the c-section closure.

Dr. Barry Eppley

Indianapolis, Indiana

April 14th, 2014

Case Study: Upper Lip Advancement in a Man

 

Background: There are many options for lip enhancement today of which injectable fillers is by far the most commonly used. But for a permanent change in size, surgical options must be considered. Two basic types of lip lifts exists done either from under the nose (subnasal lip lift)or from the edge of the top of the upper lip. (lip advancement) Each of these has their own advantage sand disadvantages but the very thin (pencil thin) upper lip can only be effectively treated by a lip or vermilion advancement.

The lip advancement procedure works because it physically moves the upper border of the pink portion (vermilion) of the lip upward. (in the case of the upper lip) By so doing, the vertical length of the lip is increased permanently which creates a bigger visible lip appearance. The lip advancement also has the advantage of being able to change and enhance the shape of the cupid’s bow of the upper lip, which frequently is flat in the lip with little vertical vermilion exposure.

While women are most commonly seen as having lip enhancement procedures, men occasionally do as well. Men usually consider lip augmentation for a very thin upper lip not necessarily to make an already decent sized upper lip just a little bigger. Men also do not usually want to have repeated procedures but would prefer a one time permanent result.

Case Study: This 40 year-old male wanted to have a permanent upper lip augmentation. He wanted have an upper lip that matched the size of his lower lip with better accentuation of the cupid’s bow. Interestingly, he had a full goatee that covered much of his upper lip perhaps as a camouflage for his perception of his upper lip size concerns.

Male Lip Advancement markings before surgery Dr Barry Eppley IndianapolisHis upper lip hairs were trimmed back to expose the amount of upper lip advancement to be done. With a calipers, a 4mm skin excision was marked (1/4 of the total philtral length)mwith a cupid’s bow highlight and lack of a taper near the corners of the mouth. Under vestibular local anesthetic blocks with direct upper lip infiltration, the skin was excised and the upper lip advanced along the line of the marks. The incision was closed with 6-0 plain sutures with a few deep 6-0 monocryl sutures. Antibiotic ointment was applied as the dressing.

Male Upper Lip Advancement result fronkt viewMale Upper Lip Advancement result side viewThe final lip advancement result with mature scars was seen four months later. While he still had a goatee, the upper lip scar was virtually undetectable and the increase in the size of the upper lip was doubled.

While there is always a concern about the scar from any lip advancement surgery, that concern is magnified in men. (because they do not ever use lipstick) But my experience in men has shown that the lip advancement scar heals well and is not more of a concern than when done in women.

Case Highlights:

1) Thin upper lip concerns in men, while not as common as in women, can be treated with the same types of lip enhancement techniques.

2) An upper lip or vermilion advancement offers a permanent solution to an improved lip size and shape.

3) Upper lip advancement scars heal well in men ( and perhap better than even in women) presumably due to the hair follicles in the skin.

Dr. Barry Eppley

Indianapolis, Indiana

April 13th, 2014

Liposuction and Fat Injections for Treating Buttock Silicone Injection Complications

 

The desire for a larger and more shapely buttocks has led to a surge in the number of buttock augmentation procedures performed today. While fat injections and implants make up the legitimate surgical methods to increase buttock size, there is a significant black market industry of buttock augmentation by a variety of unapproved injectable filler materials. The most commonly uses of these materials is silicone oil of various grades…none of them approved for human use for buttock augmentation.

Silicone Buttock Injection Complications Dr Barry Eppley IndianapolisInjecting silicone oils into subcutaneous tissues is known to potentially cause adverse tissue reactions and problems. These can include hard lumps, cellulitis and abscesses, pigmentation changes in the overlying skin and chronic pain. As a result the black market buttock injection industry has created numerous patients with chronic buttock problems….known as gluteal silicone toxicosis. This can be a very difficult problem to treat since removing the silicone material dispersed throughout the buttocks is impossible without wide excision and major buttock deformity.

In the March 2014 issue of Aesthetic Plastic Surgery, an article addressing the treatment of gluteal toxicosis appeared entitled ‘ Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region’. In this paper, liposuction was evaluated as a treatment method for this problem to maintain good buttock aesthetics and to limit the risk of complications. Eight patients (seven women and one man with an average age of 36 years old) ) were treated with combined liposuction and fat injections over a three year period. After one year after surgery, the patient’s pain levels were  completely eliminated. No patients experienced any further infections or required ER visits or need for hospitalizations.

Indianapolis Buttock Fat Injections Dr Barry EppleyThis study series support that liposuction with immediate fat transfer is a safe treatment that preserves aesthetic appearance and reduces or eliminates pain for patients with gluteal silicone toxicosis. While the liposuction extraction undoubtably does not remove all of the silicone material, it does break up the scar tissue and painful lumps of silicone and fibrosis. It then replaced this with new fat that is interspersed amongst the broken up tissue areas, creating more healthy tissue areas.

One approach that this study did not evaluate and can be considered for treating silicone buttock injection complications is what role does the liposuction play in its treatment. Since it can not remove all of the silicone and may only remove just a fraction of it, its purpose may be nothing more than to break up the scar tissue and granulomas and provide space for the injected fat. Thus, using the liposuction instruments for tunneling and not necessarily extraction may be just as effective and could result in a greater buttock size than before the treatment.

Dr. Barry Eppley

Indianapolis

April 11th, 2014

The Tissue Level of Botox Injections in the Forehead

Botox Facial Wrinkle Injections Dr Barry Eppley Indianapolis

Botox is the most common method of forehead rejuvenation used today. Literally billions of injections has been done in various locations around the brows and upper forehead over the past two decades around the world. Its effectiveness is unquestioned  and there is no indication that the number of treatments provided in the foreseeable future will be any less.

While there are variables in the administration of Botox, including dose and forehead injection locations, injecting into the forehead tissues seems straightforward. But to those who have ever done Botox injections, the forehead tissues are thick and there are a number of different tissue planes where it can be deposited. From just under the skin to all the way down to the bone, the deposition of the neuromuscular toxin can be done. But what is the correct tissue level and does it matter?

In the March/April 2014 issue of JAMA Facial Plastic Surgery an article appeared entitled ‘Subcutaneous vs Intramuscular Botulinum Toxin – A Split-Face Randomized Study’. In this paper, a study was done to determine the difference between subcutaneous (SC) and intramuscular (IM) injection location. In nineteen patients, Botox injections were done on a randomized basis so that each patient received SC injections on one side of the forehead and IM injections on the other side. At two weeks and two and four weeks after injection, the degree of eyebrow elevation by measurements was assessed. These measurements showed no differences between the SC and IM injections. IM injections were rated as having greater discomfort than SC injections.

This study showed that the SC injection of Botox is equally effective in achieving denervation of the forehead muscles as IM injections. And what is known from my experience is that the deeper the injections are placed the more uncomfortable it can be for some patients. And with no benefit for effectiveness, there is no reason to place the needle any deeper than just under the skin.

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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