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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.

August 19th, 2014

Technical Strategies in Plastic Surgery – MicroLiposuction of the Perioral Mounds

 

The removal of fat from the face by liposuction is historically seen as very limited in what it can accomplish. The large buccal fat pads can be removed by open excision but the remainder of facial fat is largely subcutaneous in location and small in volume over a large surface area. Liposuction of submental and neck fat is commonly done and very effective. Its ease of removal is largely because it is a relatively broad surface and an area that can collect substantial fat in some people. There is also little risk to any facial nerves as long as one stays below the jawline.

But above the jawline, subcutaneous fat removal by liposuction is not as generous. Fat pockets are small and often intertwined with more fibrous tissue. In addition the ability to hide small access incisions for cannula entrance is more limited. But these restrictions aside, there are facial areas where small amounts of fat can be removed.  A few ccs of fat removed may not be seem significant but on your face in the right location, its effect can be meaningful to create facial contouring/thinning effects.

Perioral Mound Liposuction Dr Barry Eppley IndianapolisOne such facial area that can have effective liposuction is the perioral region, specifically the perioral mounds. These small collections of fat beside the mouth and below the buccal pad fats create a puffiness or fullness. They are actually above the jowls although they can merge into them as well. By accessing this facial area through a small incision inside the mouth, the mound fat can be reduced and an outer convexity turned into a concavity if desired. It is important to stay in the subcutaneous space above the buccinator muscle to get the fat reduction effect.

Perioral Mound Liposuction cannula Dr Barry Eppley IndianapolisBecause this is a small area, it is necessary to use very small cannulas for perioral mound liposuction. Some may call these microcannulas or even nanocannulas depending upon what type of traditional liposuction cannula to which it is being compared. When the cannulas are this small, they will be only one hole located at the tip on one side. Multiple hole cannulas at this small size are difficult to manufacture and are prone to fracture. The area is thus treated by a double pass method, first down on the muscle and then secondly turned over and worked off the underside of the skin. (which is usually the most productive pass) A productive perioral mound liposuction may only pull out 1 to 1.5 ccs of fat at most.

Dr. Barry Eppley

Indianapolis, Indiana

August 19th, 2014

Plastic Surgery Product Review – Premvia Hydrogel Wound Healing

 

Wound healing and soft tissue regeneration requires the production of collagen and extracellular matrix to lay the foundation for cellular ingrowth from fibroblasts and epithelial cells for overgrowth. (coverage) A wide variety of biologic signals and other factors are required for this process to occur in a timely manner. Many wound healing products have appeared over the years, each with their own advantages and disadvantages.

Renevia Dr Barry Eppley IndianapolisAlong has come the newest wound healing, Premvia (BioTime Inc) which has just received FDA clearance for marketing. Premvis is the first FDA-approved product from a family of hydrogels, who mimic the natural structures of the body’s extracellular matrix. Such a structure allows for the cross-linking of collagen and hyaluronic acid. Technically this is a hydrogel formulation composed of cross-linked thiol-modified hyaluronan and thiol-modified gelatin. Due to its high water content, Premvia can donate donate water molecules to a wound surface and maintain a moist environment therein. It is also a biodegradable matrix which provides a structure onto which cells and small blood vessels can latch into to promote healing.

Premvia hydrogel can be useful for a wide variety of wounds from burns, ulcers, surgical insult, delayed healing. While this is useful at the present for open wounds, the future of this product lies in the company’s future plans to use it as a carrier of stem cells. A clinical trial in Europe is ongoing in that regard. (Renevia) This will be a much more difficult FDA hurdle to overcome but the product is worth watching to see if it will eventually turn into an injectable product that can be cell-loaded.

Dr. Barry Eppley

Indianapolis, Indiana

August 18th, 2014

Case Study: Female Subnasal Lip Lift

 

Lip Augmentation Dr Barry Eppley IndianpolisBackground: Lip rejuvenation is most commonly done by injectable fillers. By adding internal volume the lip gets bigger and, most of the time, looks more aesthetically appealing. But injectable fillers will not work for all aesthetic lip concerns. It can not reduce the amount of skin in the upper lip nor can it increase the amount of tooth show. Should these features of the upper lip need to be improved, an excisional approach is needed.

Excisional lip procedures involve the removal of skin to create their effects. This can be done either under the nose (lip lift) or from just above the upper lip line. (lip advancement) There are specific indications for either excisional lip procedure and they are often confused. Fundamentally, a lip lift only changes the central portion of the upper lip while a lip advancement changes the entire vermilion appearance of the whole lip form corner to corner. Both shorten the vertical length of skin of the upper lip and may improve tooth show. A lip lift accentuates the current shape of the cupid’s bow while a lip advancement can dramatically change the shape of it. The different location of the resultant lip scars are also obviously different.

Case Study: This 26 year-old Hispanic felt that her upper lip was too long and she did not have enough tooth show. She has very reasonable vermilion shape and fullness but she was not opposed to a more pronounced cupid’s bow appearance. She had tried injectable fillers but this did not give her the upper lip look she was seeking.

Subnasal Lip Lift skin segments removed Dr Barry Eppley IndianapolisAn irregular wavy line excision pattern was marked out under the nose in what is often called a ‘bullhorn’ shape. The maximal width of the excision was marked out along the philtral columns based on a preoperative measurement of 15.5mm length with a 5mm skin excision along these lines) The marked excision pattern tapered into the crease at the sides of the nostrils. Under local anesthesia (infraorbital nerve blocks with direct infiltration), the intervening skin segments were excised in two pieces exposing the orbicularis muscle. The lip segments was lifted and sewn in a two-layer closure with resorbable sutures. Antibiotic ointment was applied as the only dressing.

Subnasal Lip Lift immediate result front viewThe results from a subnasal lip lift are immediate as one would expect from the vertical skin shortening. While the upper lip is moved upward to be closed under the nose. There can be a slight pulling down of the base of the nose in some cases. This has led to some surgeons doing deep sutures, sewing either the muscle or the dermis of the advanced upper lip skin flap to the anterior nasal spine. This well-intentioned suture manuever is ill-advised as it can affect how the upper lip moves or cause other distortions.

Subnasal Lip Lift immediate result side viewAs long as not too much skin is removed from the upper lip (never more than 1/3), this slight pulling down effect is temporary and is not of an aesthetic concern. All subnasal lip lifts will eventually suffer some relapse of up to 20% of the skin removed, that is a far easier problem to correct if desired than any type of lip distortion caused by muscle manipulation or deep suturing manuvers.

Case Highlights:

1) A subnasal lip lift is an effective lip enhancement procedure whose effects are limited to the central portion of the upper lip. (cupid’s bow)

2)  A subnasal lip lift will shorten the upper lip with a minimal effect on increasing upper tooth show.

3) A subnasal lip lift should not remove than one-third of the vertical skin distance between the nose and the lip and should never remove or plicate the orbicularis muscle.

Dr. Barry Eppley

Indianapolis, Indiana

August 17th, 2014

Technical Strategies in Plastic Surgery – Fat Injections for Brow Bone Break Reduction

 

Fat injections have tremendous popularity due to their autologous (natural) source, ease of graft procurement and ability to place the graft in a scar-free manner. While fat graft retention is far from assured, they have been used in a tremendously diverse number of applications where more soft tissue volume is needed.

One such unique application of fat grafts is for forehead recontouring. Historically this is a facial bony augmentation location where applying bone cements or implants is needed to create an outward effect. But surgical incisions are needed, usually in the scalp, for these aesthetic surgeries and that may be more of a scar burden that is worth it to some patients and for some forehead augmentation needs.

One relatively minor aesthetic forehead concern is the presence of or an overly deep brow bone break. Usually seen in men as a masculine feature this is caused by prominent brow bone development (technically frontal sinus growth) that extend out further than the plane of the forehead. This causes an obvious horizontal line of demarcation between the contour of the brow bone and the forehead above it.

fat injections to brow bone dr barry eppley indianapolisfat injections to forehead dr barry eppley indianapolisThe brow bone break can be softened or eliminated by fat injections. It is important to use highly concentrated fat and inject it in a microdroplet technique using the smallest microcannula. This is done through small nick incisions created by a 20 gauge needle along the horizontal break line. Two layers are placed, one above and the other below the galea. This careful and discreet fat injection technique is easy to do since the volume administered is usually less than 5ccs.

Fat Injection to Brow Bone Break Dr Barry Eppley IndianapolisSmall volumes of fat carefully placed can be an effective technique for brow bone break reduction/elimination. Given that the aesthetic problem hardly justifies a more extensive operation, this fat injection technique can be a minimally invasive and sustained forehead recontouring method.

Dr. Barry Eppley

Indianapolis, Indiana

August 16th, 2014

Case Study: Revision Rhinoplasty for the Under Rotated Nose

 

Background: Rhinoplasty can create a diverse number of nose shape changes. One of the most commonly requested nose changes, particularly amongst women, is to have more tip rotation. (not hang so low) Overgrowth of the underlying caudal septum and long lower alar cartilages help create the length or amount of projection and rotationof the nasal tip from the rest of the nose. These long tip cartilages almost always cause the nasolabial angle to close down, creating the under rotated tip effect.

Nose Job Indianapolis Dr Barry EppleyIn a primary rhinoplasty, the nasal tip can be shortened/lifted through a combination of caudal septal relief and/or lower alar resection through dome or more lateral crural techniques. It is always a challenge to determine how much of these cartilages to remove to provide the amount of tip shortening/rotation desired. And the result from doing these maneuvers is not always prefect particularly in the thick-skinned nose. If the nose is still persistently long or hangs down too low, a revision rhinoplasty may be needed for further tip shortening and/or rotation.

Case Study: This 40 year-old female had two prior rhinoplasties by another surgeon to reshape her nose. This left her with dorsal irregularities and a long and ill-defined tip with inadequate rotation. While she had two prior procedures, she was still interested in trying to make further improvements if possible.

Long Nose Rhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia, an open rhinoplasty approach was used. Dorsal smoothing was done by rasping of bone spurs on the upper edges of the nasal bones. The nasal tip was sharply cleaned of all scar tissue over the domes and in the supratip area. A 2mm wedge of cartilage was taken from the upper caudal septum. (septal angle) A dome division technique was used to shorten the tip as well as narrow it and rotate it upward.

Long Nose Rhinoplasty result oblique view Dr Barry Eppley IndianapolisLong Nose Rhinoplasty result front view Dr Barry Eppley IndianapolisTertiary rhinoplasty (2nd revision rhinoplasty) has limits as to what can be achieved, particularly in the tip area. Scar tissue and skin changes make it less capable of being shaped and more resistant to efforts at any additional refinement. This is particularly manifest when it comes to giving the thicker skinned nose more rotation and opening up the nasolabial angle. This result demonstrates that changes are possible with visible shortening and rotation but very limited improvement in tip refinement.

Case Highlights:

1) Shortening a long nose is a common objective of many rhinoplasty surgeries due to congenital overgrowth of the lower alar cartilages and septum.

2) A long nose can also persist or occur after a primary rhinoplasty from over resection of the dorsum and/or failure to remove adequate cartilage from the nasal tip.

3) Revision rhinoplasty can correct the residual long nose through conventional tip shortening/reshaping techniques but further tip narrowing refinement may be elusive

Dr. Barry Eppley

Indianapolis, Indiana

August 16th, 2014

Postoperative Instructions: Testicular Implants

Testicle Implants Dr Barry Eppley IndianapolisThe loss or absence of a testicle in a man can have adverse psychological effects. Testicular implants (also called testicular prostheses) are a relatively simple surgical procedure that can lead to an improved body image for those men so affected. It is done through a small incision in the scrotum and takes less than one hour to perform under anesthesia. Based on Dr. Eppley’s experience, these are the most common considerations to know after testicular implant surgery.

1.  Testicular implants usually have a low amount of postoperative discomfort but the scrotum will feel a little tight. Take your pain medications as needed. Significant swelling will occur in the first few days (peaking the second day after surgery), making it more swollen than seen the first night after surgery. This is normal.

2. Apply ice packs (frozen peas or mixed vegetables work well) to the groin area over the implanted side for the first 24 hours to help with swelling. This will keep down some but not all of the swelling.

3. If your job involves deskwork or very light activity, you may return to work 2 or 3 days after surgery. Remember that it is likely that you will have some discomfort for the first few days after surgery when deciding when to go back to work.

4. You may sit and do all activities as you normally would do, short of exercise during the first week after surgery. It will be helpful to have underwear that does not fit too tight but provides good support.

5.  There will be no dressings applied. Only a layer of glue will be over the scrotal incision. The glue will fall off in several weeks after the procedure.

6.  You may shower the next day after surgery and do not worry about getting the incision wet. Do not take a bath or submerge the incision under water for ten days after surgery. (like a hot tub)

7.  All of the sutures will be dissolvable and underneath the skin. You may see a few small sutures on the outside of the incision but these also are dissolvable.

8. Numbness of the skin around the scrotum is normal after this kind of surgery. Normal feeling will return but it may take up to several months after surgery for that to occur.

9.  You may participate in any physical activity that feels comfortable, including exercise. You should avoid running or sex for one week after surgery.

10. If any redness, tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

August 15th, 2014

Case Study: Submental Relaxation after Facelift Surgery

 

Background: Facelift surgery is very common and is the single most effective procedure for correcting aging issues of the jowls and neck. By removing excess fat in the neck and jowls, tightening the platysma muscles and redraping loose skin up toward the ears and temporal hairline, a recontouring of the lower face is achieved. In every case of a facelift, the immediate surgical change is often dramatic and the more advanced the aging the more dramatic the change will be.

But no matter how a facelift is done, it has significant reliance on tissue pull particularly that of the skin. Because the skin is an elastic structure, there is always going to be some eventual recoil from the stretch imposed on it.  (not to be confused with eventual ongoing aging but a relatively immediate after surgery effect) In a facelift this is most commonly seen in the submental region. This point is exactly centered between the two sides of the pull on the sides of the face. Because it is so far from the area where the pull is exerted, it is the first facial area to show some ‘relapse’ as a result of this tissue relaxation phenomenon.

Case Study: This 40 year-old female wanted to improve her neck and jowl sagging. Despite that she was fairly young, her neck changes were more significant than her chronological age would indicate. She had fat and loss of her cervicomental angle. Her skin was also very thin and elastic which undoubtably made a contribution to her early tissue sag.

Limited Facelift result side view Dr Barry Eppley IndianapolisUnder general anesthesia, her submental and neck regions were initially evacuated of some fat by liposuction. Through a submental incision, the neck skin was widely undermined. A retrotragal preauricular and postauricular incisional approach was done around the ears to undermine the skin until it connected to that of the neck. Using a sutured SMAS plication technique done in differing vectors, the deeper tissues were lifted and tightened. The skin was then lifted and draped up over the ears, trimmed and the incisions closed.

Limited Facelift result oblique view Dr Barry Eppley IndianapolisHer four month facelift result showed a significant improvement in her neck and jawline. While the change could be called dramatic, some tissue relaxation had settled into the submental area under the chin. This was different that what was seen in the first few months after her surgery.

A suhmentoplasty procedure can correct the immediate tissue relaxation effects that can occur after many facelifts that have corrected significant neck changes. This can be done with with a crescent or an inverted T type skin excision pattern. It is prudent to advise patients that such tissue relaxation can occur and it is not rare. A submentoplasty for correction of submental skin relaxation after a facelift can be performed anytime six months to a year after the original facelift procedure.

Case Highlights:

1) Facelift surgery commonly undergoes some relaxation of the tissues as they heal and relax from the initial stretching forces.

2) Skin relaxation after a facelift is frequently seen in the submental and central neck area which is furtherest from the point of skin excision and pull. (ears).

3) A submentoplasty procedure may be beneficial six to twelve months after a facelift to ‘retighten’ the central neck area if any skin sag develops.

Dr. Barry Eppley

Indianapolis, Indiana

August 13th, 2014

Drainless Tummy Tucks Using A Surgical Adhesive

 

The concept of a drainless tummy tuck has been around for several years now and has met with mixed success. Some plastic surgeons claim they never place a drain and do not have any seromas while others almost always place drains with a low incidence of problems including seromas. Patients would obviously not like to have a drain so the appeal not to use one is high.

The current drainless tummy tuck relies on the use of quilting sutures to close down the deep space that lies underneath the skin flap. While effective, it takes additional time and adds expense to place the number of quilting sutures needed. And it is not completely complication free with reported instances of dimpling of the abdominal skin and rarely as a cause of skin necrosis.

A new advance in the drainless tummy tuck is the use of a tissue glue to supplant the current use of sutures. By applying an adhesive substance inside the abdominal wound, the dead space would be largely eliminated through adhesion of the underside of the skin flap to the abdominal wall fascia. In essence, gluing the inside of the wound together and eliminating the space where fluids can accumulate.

TissuGlu No Drain Tummy Tuck Dr Barry Eppley IndianapolisTissuGlu (Cohera Medical) is a new high-strength surgical adhesive. It is a single component adhesive that begins as a low molecular weight, hyper-branched pre-polymer that cures in the presence of moisture. It cross-links to itself and the surrounding tissues to form a strong bond between layers. The cured adhesive remains soft and flexible through its network of large polymeric chains. But it eventually breaks down and is absorbed as the wound heals over time. It also has the advantage, unlike other tissue adhesives, that it requires no mixing and can be stored at room temperature.

No Drain Tummy Tuck TissuGlu Dr Barry Eppley IndianapolisTissueGlu surgical adhesive recently completed a clinical trial for tummy tucks. The purpose of the trial was to determine if TissuGlu was an effective alternative to the use of drains for the prevention of postoperative seromas. In 130 patients (66 TissuGlu, 64 drains) with a ninety day follow-up, patients underwent a lower need for after surgery aspirations than when drains were used and had a quicker return to normal activities.

The need to aspirate a fluid collection (seroma) after a tummy tuck is not rare. Even in patients that have a drain in place for 7 to 10 days after surgery, the incidence of seromas approximates about 30% in my practice. While never requiring the need for additional surgery, the prolonged need for weekly aspirations places a burden on the patient with an increased number of office visits and some level of chronic discomfort.

TissGlu appears to be a safe and effective method that has a role in tummy tuck as a useful adjunctive aid. It now awaits formal FDA approval and the company to set a price of the surgical adhesive…which will determine what role it will ultimately play in tummy tucks which are most commonly done on a cosmetic fee basis.

Dr. Barry Eppley

Indianapolis, Indiana

August 11th, 2014

Botox Injections for Lower Facial Contouring (Masseter Muscle Reduction)

 

The large masseter muscle (masseteric hypertrophy), unlike the prominent bony jaw angle, does not have a surgical solution. Surgical muscular reduction is associated with a high rate of complications and potental disability. As a result, the use of botulinum toxin type A injections (most commonly Botox) has become the standard of treatment to improve lower facial contour due to large masseter muscles.

There is little question that Botox into the masseter muscles can be effective but there is little standardization in dose and injection points of treatment. Dosage amounts vary amongst practitioners as well as treatment schedules. Long-term outcomes of a sustained effect remain wanting.

In the August 2014 issue of Plastic and Reconstructive Surgery, a paper on this topic was published entitled ‘Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment’. In this  paper over 500 masseter muscles were classified into bulging types with three degrees of thickness. Over 200 patients were treated with Botox injections of 20 to 40 units per side with one to three injection sites per muscle. After injection, masseter muscle thickness decreased by an average of roughly 33% (13mms to 9mms approximately) as measured three months later. There was a corresponding improvement in the width of the lower face to the upper facial intercanthal distance. Overall patient satisfaction was 96% without any serious complications.

This study provides evidence in a large series of patients that an injectable approach to massteric muscle reduction is effective. Its maximum effect occurs by three months after treatment with a visible reduction is lower facial width. Dosages in units should be increased based on the muscle characteristics anywhere from 20 to 40 units per side. It is important to keep the injections into the bulk of the muscle closer to the jaw angle area to avoid a temporary weakening effect on the buccal branches of the facial nerve.

What this study does not address is how long this muscular facial thinning effect lasts and how many treatments it takes to achieve its maximal effects. It is still unclear as to whether Botox causes a permanent muscle atrophic result in the muscles of mastication.

Dr. Barry Eppley

Indianapolis, Indiana

August 10th, 2014

Technical Strategies in Plastic Surgery: Columellar Skin Grafting in Cleft Rhinoplasty

 

Reshaping the nose in the cleft patient represents one of the more challenging of all rhinoplasty surgeries. Efforts are made a various time periods from the initial cleft lip repair to teenage years to make nose corrections. But the tissue deformities inherent in the cleft nose almost always defies a completely satisfying result.

Of the many well known anatomic problems in the cleft nose, a columellar skin deficiency is one of them. This is most manifest in the bilateral cleft patient but exists to a lesser degree in the unilateral cleft as well. This lack of columellar skin length can mar an otherwise good realignment and reshaping of the tip cartilages at the completion of an open rhinoplasty. As when the skin is closed over the reshaped tip, the lack of columellar skin will pull down on the uplifted side of the dome causing a distortion of the nostril height and shape on the cleft side.

Different surgical strategies have been used to address this issue including columellar lengthening through V-Y lengthening closure methods. But they are not always successful in more severe unilateral cleft noses.

cleft rhinplasty columnellar skin graft dr barry eppley indianapoliscleft rhinopalsty skin graft dr barry eppley indianapolisSince lack of skin is the problem, an alternative approach would be the use of a small skin graft placed into the deficient columellar skin side. This requires a very small skin graft which can be easily harvested from the back of the ear. Like all skin grafts, take of the graft is enabled by graft immobility and compression. This is less important with such a small graft in a well vascularized area such as the nose. But the use of a nasal stent or conformer can assist in this regard.

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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