Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

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

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

March 29th, 2014

Plastic Surgery Children’s Book – Ellie Hears An Elephant


Children and teenagers can be afflicted by numerous types of physical birth defects, some of which cause medical problems and others which are more about looking different and being less than ‘perfect’.  With a developing and sometimes fragile self-image, prominent appearance differences can be a potential source of embarrassment. Plastic surgeons see children and young teens for several basic types of aesthetic surgery. One of the most well known is that of protruding or prominent ears. Caused by the lack of development of one the ear folds or overgrowth of some of the cartilage at its base, the ears can stick out quite distinctly from the side of the head. Such ears are evident right after birth and do not change or become less obvious as the child grows. They frequently can become a source of ridicule, which does not usually occur until they have begun formal schooling

Plastic Surgery Children's Book Ellie Hears An Elephant Dr Barry Eppley IndianapolisIn a new children’s book ‘Ellie Hears An Elephant’ written by Indianapolis plastic surgeon Dr. Barry Eppley and his daughter Hannah, the story of a young girl and her experience with elephants is told. What starts out as an innocuous trip to the circus to see her favorite zoo animal eventually turns into a source of teasing and embarrassment. Grappling with the decision as to whether to change her natural self requires input from those closest to her…her parents and her sister.

So what is Ellie to do? Her parents take him to a local plastic surgeon to find out what can be done. Should she make a change or not? That is the decision that only she can ultimately make.

Elective plastic surgery in children and teenagers has always been a sensitive subject. Whether one should change how they look for a prominent physical feature touches on the issue of a developing self-image and their psychosocial development. Should plastic surgery be done and is it necessary for one’s ‘health’? Like Ellie and her ears, such decisions are personal ones but fitting in and being accepted as normal can have a profound influence on that choice.

March 27th, 2014

Forehead Injectable Fillers and the Risk of Vision Loss


Injectable fillers, along with Botox, have revolutionized the treatment of the aging face particularly one early in the process. The number of such injectable facial treatments around the world must surely number in the billions at this point in time over the past twenty years. The typical complications from injections are largely aesthetic and are well known. There are few major complications that have been reported, of which skin loss or necrosis is the most dire consequence.

Forehead Injectable Fillers Dr Barry Eppley IndianapolisIrreversible vision loss can now be included in the list of major complications from injectable facial fillers. In the March 2014 issue for JAMA Ophthalmology, an article appeared entitled ‘Cosmetic Facial Fillers and Severe Vision Loss’. In this paper, three patients were reported that had central retinal artery occlusion right after receiving injections of different injectable facial fillers in the forehead area. All three patients had injections of either a hyaluronic acid filler, fat and Artefill in the high forehead area. Adverse changes to the retinal circulation were demonstrated by fluorescein angiography. All three patients had persistent visual field defects that did not resolve.

While there have been previous reports of eye complications from injections of other facial areas, this is the first report of it happening from injections into the forehead. While extremely rare, the highly vascularized tissues of the entire periorbital area make it an ever present albeit remote possibility.

Retinal Artery Occlusion from Injectable Fillers Dr Barry Eppley IndianapolisThe cause of injectable filler vision loss is retrograde flow. Since all fillers are injected through the smallest needle as possible, they are done so under higher pressure. The more viscous the filler material, the higher pressure that it comes out of the needle. According to the authors of this paper, when an injection is made under a higher force the injected substance gets into the external carotid vessel at a high enough force that it flows backward into the internal carotid and into the eye. This results in occlusion of the central or branch retinal artery or the posterior ciliary circulation, both of which branch from the ophthalmic artery. All three reported patients demonstrated choroidal filling defects and retinal arterial involvement.

According to the American Society of Plastic Surgeon’s statistics for 2013, well over two million injectable filler treatments were performed…and this number does not include every other type of doctor who may perform them. Even if these were the only cases of visual problems that have occurred in a single year, this places the risk at 1 in a million or  more treatments. While rare, it can still happen and the best way to avoid it is to use microcannulas for injections and not needles. This makes it much harder to inadvertently enter the vessels around the eye.

Dr. Barry Eppley

Indianapolis, Indiana


March 26th, 2014

Diced Cartilage Graft Rhinoplasty Wrappings


Cartilage grafting to the nose for significant dorsal augmentation almost always requires a rib graft for the volume needed. A rib graft provides ample amounts of graft material to augment the nose to just about any degree but it does have a well known tendency for warping. Even a well carved and positioned rib graft placed on the nasal dorsum does not always guarantee that it will forever remain perfectly straight.

Diced Cartilage Rhinoplasty Indianapolis Dr Barry EppleyThis one drawback to nasal rib grafting has led to the re-emergence of changing the stiffness of the rib cartilage into a diced shaped graft. This is an historic nasal grafting method known as a ‘Turkish Delight’ as originally described by the Turkish surgeon Erol.  By changing a one-piece stiff rib graft into hundreds of small 1mm cubes, it can be shaped and adapted to the desired nasal form and there is no chance of warping or graft distortion.

But to successfully place a diced cartilage graft into the nose, the many small cartilage ‘cubes’ must be placed into some type of containment sac to create a moldable cartilage graft. This has historically been done with the use of a Surgicel wrapping. Surgicel is best known as a hemostatic agent that was introduced long ago in 1947. It is composed of an oxidized cellulose polymer and comes as a very pliable mesh sheet. It can be rolled into a ‘sausage casing’ to contain a diced cartilage graft.

Alloderm in Rhinoplasty Dr Barry Eppley IndianapolisWhile easy to use, the enveloping Surgicel has been criticized as causing a mild inflammatory reaction as it resorbs and could cause the cartilage graft to resorb. This has led to the use of tenporalis fascia as the wrapping which experimental studies have shown to not induce a similar inflammatory reaction due to its autogenous nature. However, harvesting temporalis fascia requires a donor site and an associated temporal scalp scar.

In the August 2011 issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery, a study was reported whose aim was to compare the viability of diced cartilage wrapped in autogenous fascia to diced cartilage wrapped in AlloDerm in a rabbit model. Diced cartilage grafts wrapped in lumbar fascia vs Alloderm were compared after six months of implantation by standard and immunohistochemical staining. Their histological analysis showed that the chondrocyte regeneration potential, matrix collagen content, and metaplastic bone formation of the AlloDerm-treated group were significantly superior to those of the fascia-treated group. With respect to other histological parameters, the AlloDerm-treated group showed better results than the fascia-treated group, but these results were not statistically significant. Their experimental results indicate that AlloDerm may be an excellent material for diced cartilage grafting. At the least, it appears as if it is just as good as autogenous fascia.

Surgicel Diced Cartilage Rhinoplasty Dr Barry Eppley IndianapolisWhile this was a limited animal study, it makes perfect sense that an allogeneic dermis would offer similar advantages to fascia with one significant exception…it does not require a donor site. As long as the Alloderm layer is not too thick (less than 1mm or 65/1000s of an inch), revascularization of a diced cartilage rhinoplasty should happen fairly quick.

Dr. Barry Eppley

Indianapolis, Indiana

March 24th, 2014

Plastic Surgery Humor: Age and the ‘Need’ for Plastic Surgery


Age and the Need for Plastic Surgery Dr Barry Eppley IndianapolisOne’s perception of the ‘need’ for plastic surgery of the aging face is a matter of perspective as this word cartoon illustrates. I have heard many patients who are having some form of a facelift that their children are mortified that they are having the procedure. These younger children are not infrequently firmly against any form of physical self-change…and this is actually understandable. As I often say…when you don’t have the problem you don’t understand the need. No younger person can really see themselves as ever being older so it is easy to say what you feel now before you ever have had the actual problem. Age and the development of the problem will frequently change how one feels.

It is usually around the 40s that one begins to think that plastic surgery of some form may be inevitable or no longer seems like a bad idea. This is most relevant to the aging concerns around the eyes.  Botox injections has probably moved that age range younger as someone getting Botox in their 30s is not rare and this is an age when more invasive surgery is not needed anyway.

But the time one is in their 50s those so inclined may have already had some form of plastic surgery…even if they will not openly admit it.

Dr. Barry Eppley

Indianapolis, Indiana


March 24th, 2014

Case Study: Male Tummy Tuck after Weight Loss


Background: Tummy tuck surgery is most frequently thought of as a female procedure. Changes due to pregnancy and weight are the source of the need for improvements in a female’s abdominal and waistline shape. But men do occasionally undergo tummy tuck surgery but pregnancy is obviously not the reason. Weight loss is the exclusive reason  in men whether it is due to bariatric surgery or created by diet and exercise alone.

Male Tummy Tuck Surgery Indianapolis Dr Barry EppleyWhen men lose a lot of weight, they have a better skin retraction than most women. They usually do not have as much loose skin as women due to better elastic properties. The skin is thicker with more elastin fibers and has not been stretched out by the expansile effects of pregnancy. As a result, their abdominal pannuses are much smaller and do not wrap around the waistline as far.

Conceptually a male tummy tuck is no different than in a woman. The excision pattern is marked out based on the excessive and loose abdominal skin and may or may not go above the belly button. But the one key difference is that men do not usually need any muscle tightening through midline fascial plication. They simply do not have a rectus diastasis.

Case Study: This 35 year-old male had lost over 100lbs using diet and exercise alone. He became an avid workout person who lifted weights and ran regularly. He felt that he had done as much as he could on his own but could not get rid the residual loose skin. He now sought a surgical solution.

Male Weight Loss Tummy Tuck result front view Dr Barry Eppley IndianapolisUnder general anesthesia, a low horizontal excision pattern of skin and fat was removed  from the lower abdomen below the belly button. The umbilicus was detached from its midline abdominal wall attachments to allow it to be moved lower to unravel loose abdominal skin that existed above it. No abdominal wall muscle tightening was needed or done. Prior to fascia and skin closure, the base of the belly button was reattached back to the abdominal wall fascia. Liposuction was then performed around the waistline into teh flanks and up the sides of the abdominal wall.

Male Weight Loss Tummy Tuck result oblique viewRecovery was very typical for a more limited form of a tummy tuck, particularly when no drain is used. It took him about three weeks before he could return tiowalking and six weeks for heavy exercise again.

Many male tummy tucks are very similar to a mini-tummy tuck in women. The tissue excision pattern is somewhat similar and an umbilical repositioning from underneath is also commonly needed. The lack of muscle tightening is the one difference.

Case Highlights:

1) The need for a tummy tuck in a man is almost universally due to a significant amount of weight loss.

2) Extreme amounts of male weight loss result in some loose lower abdominal and waistline skin that often can not be eliminated by diet and exercise alone.

3) The male tummy tuck involves the removal of loose lower abdominal skin but muscle tightening is rarely needed unlike that of a female tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

March 22nd, 2014

Black Market Cosmetic Injections and Pulmonary Embolism


The past few years have seen an increase in the number of cosmetic injectable catastrophes. They are easy to find since every one these injection problems appear quickly on the internet. All of these have been done by amateur non-medical people and, in some cases, the patients themselves who have suffered the severe complications including death.

Most commonly these black market cases involve injections to the buttocks of various materials from caulking compounds to silicone oils. But an injection death appeared this month from Argentina that involved breast augmentation. It was not only unusual because it involved the breasts but because of what was injected into them.

Vaseline Breast Augmentation Dr Barry Eppley IndianapoisA 39 year-old Argentine athlete and mother paid the ultimate price when she injected Vaseline for a do-it-yourself (DIY) breast enhancement. After experiencing breathing difficulties and taken to a hospital, it is reported that she admitted that she had injected the material into her breasts several weeks earlier. She subsequently died of pulmonary complications later.

But what was it that actually caused her demise? Clearly it was due to the vaseline but why did it takes weeks to exert its lethal effect? Most would think of localized infection and ultimately systemic sepsis as the culprit. While this is a valid risk with any unsterile non-approved implant material, the bigger risk of black market injections is less obvious but even more lethal.

Pulmonary Embolism from Black Market Injections Dr Barry Eppley IndianapolisKnown as pulmonary emboli or PE, these are fatal clots or obstructions in the lungs. While a well known lung complication from blood clots in the legs (hence the term throwing a clot), a blood clot breaks lose from the bigger veins in the legs and travels to the lung. Once in the lungs, which have smaller sized blood vessels, the relatively large clot gets stuck and wedged into the smaller ‘pipe’. Once stuck it causes that portion of the lung to be unable to exchange air and collapse from which lung failure can occur. In these black market injections, it is a small piece of the injectable material that becomes wedged into a lung artery. In this unfortunate Argentine woman, it was a mobilized piece of vaseline that became the culprit of her lethal PE. Once wedged in place, a severe inflammatory process ensues to the petroleum jelly and the lung eventually collapses.

Between severe infection and pulmonary emboli, one is far more likely to die from a PE from black market injections. Infection can be treated by drainage and IV antibiotics but a PE has little effective treatment, and by the time that it is discovered, the patient is often dead. This risk is never even considered due the complete lack of any medical knowledge of the injector.

Dr. Barry Eppley

Indianapolis, Indiana

March 20th, 2014

The Use of Drains in Gynecomastia Reduction Surgery


Gynecomastia  Reduction Dr Barry Eppley IndianapolisGynecomastia reduction surgery is very common for either young or middle-aged males who have various amounts of breast tissue development. While some forms of gynecomastia are treated by liposuction alone, more than half of them require an open approach through an inferior areolar incision. When doing an open gynecomastia reduction, it is common practice to insert a drain to prevent an after surgery fluid collection.

While the use of a drain out the side of the chest is not usually in place for very long after surgery (a few days up to a week), it is still an annoyance to the patient. Like the use of drains in other procedures like breast reduction and facelifts, the question is often raised as to their true need. It may be tradition to use them but are they really necessary

In the March 2014 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Necessity of Suction Drains in Gynecomastia’. In this paper, the authors looked at their complication rates in gynecomastia reduction surgery when no closed suction drains were used. In 138 consecutive men who had gynecomastia reduction by ultrasonic-assisted liposuction both with and without the pull-through technique. The average of the patients was around 30 years old. The amount of fat removed from each side of the chest was around 350ccs. The pull through was needed in 23 patients. (17%) They had only one hematoma and no seromas. These results lead the authors to conclude that the use of drains is not needed in gynecomastia reduction.

It is important to realize when looking at these study results that less than 20% of the patients treated had an open excision of the gynecomastia tissue, which is the main indication for the use of a drain. Drains are never used in chest liposuction. Thus, this study is not convincing that there is no value whatsoever for drains in gynecomastia surgery. I would be a lot more convinced if all 138 patients in the study had an open pull through technique done.

What this study does demonstrate is that smaller amounts of breast tissue removed through an open areolar approach is probably not needed. But for larger amounts of breast tissue removed, particularly in combination with liposuction in the surrounding chest, a few days of a drain would not hurt.

Dr. Barry Eppley

Indianapolis, Indiana

March 17th, 2014

Case Study: Skull Dimple Correction by Augmentation Cranioplasty


Background: While the shape of the skull is typically smooth, it is not rare that one may have various small contour deformities. These could be raised or indented areas depending upon their location on the skull. Many of these skull shape issues are related to their initial formation through the cranial sutures and their fusion posts known as fontanelles.

Skull Fontanelles Dr Barry Eppley IndianapolisAt birth a baby has six distinct fontanelles. The larger anterior and the somewhat smaller posterior fontanelles in the midline are the most noticed due to their size. These well known soft spots are where the skull bones have not yet fused. They exist to allow the skull plates to move, permitting easier passage through the birth canal as the head is able to change shape. After birth, they allow the baby’s brain to grow since the skull is not a fused box of bone yet. The anterior fontanelle may remain open until about 18 months of age while the posterior fontanelle usually closes by 3 to 4 months of age.

But sometimes when the fontanelles fuse, they may not fill in completely with bone of normal thickness. There may no longer be an open area between the bone edges but a complete outer and inner cortex with a well formed diploic space may not fully form. This creates an indentation in the skull or a skull dimple which appears as a circular midline depression which feels like a small crater.

Skull Dimples Indianapolis Dr Barry EppleyCase Study: This 27 year-old male was bothered by a depressed area, about the size of his thumb, on the back of his head. The overlying skin was contracted inward and the whirl pattern of his hair was directly over it. The indentation was firm with no dural palpations and was located over the area of the original posterior fontanelle.

Skull Dimple before and intraop Dr Barry Eppley IndianapolisSkull Dimpleplasty Dr Barry Eppley IndianapolisUnder combined sedation and local anesthesia, a small curved incision was made behind the skull dimple. The firmly adherent soft tissues were elevated out of the bony indentation as well as around the rim of the bony defect. The defect was then filled to the level of the surrounding skull bone with an hydroxyapatite bone cement. The scalp was closed with small resorbable sutures. A compressive dressing was then applied.

There is always some small amount of scalp swelling afterwards and, occasionally, some fluid will accumulate over the augmented area. This always resolves in a few weeks as the fluid is absorbed and the final skull contour appreciated.

Skull dimple correction is the smallest form of an onlay cranioplasty. It is simple, effective and has no real recovery associated with it. Any form of bone cement will work to fill the defect. Whether it is an open or a more injectable approach, the technique chosen is the one that can create the smoothest skull contour.

Case Highlights:

1) It is not rare for the skull to have indentations or dimples, most commonly occurring at the location of a previous fontanelle.

2) Skull dimple augmentation or skull dimpleplasty is a limited skull procedure that fills in the bone defect by application of a bone cement material.

3) Skull dimple augmentation can be done through either a small open incisional approach or an even smaller incisional injection technique.

Dr. Barry Eppley

Indianapolis, Indiana

March 16th, 2014

The Selfie Influence on Plastic Surgery


Selfies and Plastic Surgery Dr Barry Eppley IndianapolisThe term ‘selfie’ has become a popular urban term which refers to a self-portrait usually taken with a camera phone. They are usually spontaneous and casual in nature, typically taken at arm’s length or in a mirror and may include just the holder or as many other people that can be gotten into focus. The popularity of the selfie is their relationship with social networking sites like Facebook, Snapshot and Instagram, where they can be posted and shared.

The selfie is a unique social phenomenon as it allows one to create and share pictures of themselves, often taken at angles and in locations that show the person in a flattering light. While some selfies are done for comedic purposes and are less than flattering images as a form of selfie parody, the selfie still makes a statement about societal views of body images, narcissism and sexuality.

A recent study from the American Academy of Facial Plastic Surgery suggests that the rising popularity of the selfie is also causing an increased demand in plastic surgery. The study found that one out of three plastic surgeons surveyed felt they had an increase in requests for surgical and non-surgical procedures because of the influence of self-awareness by social media. Placing one’s face under the microscope by these pictures to be judged by the person and many others as well makes one ever more critical of themselves. This is particularly true amongst young people, who are the greatest users of social media by percent, as they show their faces to friends, family and potential romantic interests and employers. Putting your best face forward has totally taken on a whole new meaning.

The selfie influence on plastic surgery parallels that of other ‘mirror’ type technologies such as FaceTime, Skype and the camera phone in general. There is no question that one has the opportunity to see themselves in greater frequency today than since the invention of the mirror (Roman times) and the instant polaroid camera. (1948) Such self-scrutiny inevitably leads to greater awareness and a desire to make changes, whether they are realistic or not.

But the selfie influence is just a very small reason for the increasing numbers of plastic surgery being requested and done. It fits into a broader change in overall societal and cultural influences. As the entire world becoming visibly connected, one’s presence on this earth is at the same time minuscule but potentially very relevant.

Dr. Barry Eppley

Indianapolis, Indiana

March 15th, 2014

Age of Effectiveness for Neonatal Ear Molding


Ear deformities are not rare in newborns and there are many variations of them. Given the complexity of how the ear forms from six separate cartilage islands in utero, it is no surprise that there are going to be birth defects associated in their shape. It is well known that some neonatal ear forms can be reshaped by early modeling of the ear cartilage. The question is how early does neonatal ear reshaping need to be started to be most effective.

Ear Buddies Dr Barry Eppley IndianapolisIn the January 2012 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery, a paper was published entitled ‘A Prospective Study on Non-Surgical Correction of Protruding Ears: The importance of Early Treatment’. In this paper, a study of 209 ears in 132 babies was done using a splint in the scaphal hollow in combination with tape (Earbuddies). Treatment continued until the desired shape was obtained visually. Roughly 20% of the ears treated (27 patients) had to stop treatment due to skin irritation or device fixation problems. In those that completed treatment, results were judged as good in 1/3 fair in 1/3,  and poor in 1/3. The effectiveness of ear splinting decreased with the age of initiation with mainly poor results after six weeks of age. Older children needed to be splinted longer.

It is not uncommon to get contacted by a mother sometime in the first month or two after birth about their infant’s ear deformity. They want to know if it is too late to start ear molding therapy. While it is known that the ear cartilage becomes stiffer quickly as the infant grows, it has never been specifically determined at what age is too late to begin treatment. This study shows that when considering device molding therapy for misshapen ears, a reasonable chance of success can only be offered to parents of children up to six weeks of age.

Even when beginning ear molding at the right time, a certain percentage (about one-fifth) of patients will not be able to have a successful result due to problems with tape irritation and instability of the device. But for those infants that complete the therapy successfully, they have a significant chance of avoiding the need for otoplasty surgery later in life.

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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