EXPLORE
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 3rd, 2014

Case Study: Skull Reshaping for Occipital Plagiocephaly in a Child

 

Background: Occipital plagiocephaly is a well known benign skull deformity that causes a rather classic flat spot on the back of the head. It is frequently present at birth due to the positioning of the neonate head in the womb. It can also be caused by positioning of the baby during sleep causing a constant pressure force on one side of the back of the head. Regardless of the cause, occipital plagiocephaly can be improved by positioning techniques early after birth or molding helmet therapy in the first year of life.

Flat back of the Head Dr Barry Eppley IndianapolisBut once occipital plagiocephaly persists beyond one year of age, there are no external methods that can create a significant correction. Cranial vault remodeling can be done but the extent of this surgery makes it only justified in the most severe cases. Otherwise, flat spots on the back of the head must be endured to perhaps be dealt with as an adult if its appearance is a concern.

Skull augmentations in adults are not infrequently done for a variety of shape issues from the forehead to the back of the head by onlay cranioplasty methods. Through scalp incisions of various lengths and locations, different bone cement materials can be applied and shaped to change the skull contours in the treated area. Most commonly, the bone cement material is PMMA (acrylic) due to its lower cost and easy shaping in tight spaces.

Case Study: This 4 year-old male child had a moderately flat right occiput. On examination it could be seen that he had many of the typical findings for occipital plagiocephaly with some contralateral skull flaring/widening and a more forward position on the flattened. The parents were concerned with his degree of skull deformity and wanted to see it improved before he was much older and potentially subject to peer criticism.

Mimix Hydroxyapatite Bone Cement Skull Augmentation Dr Barry Eppley IndianapolisHydroxyapatite Bone Cement Occipital Augmentation Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, an incision was made above the back of the head but just across the top with no temporal extensions. The entire skull bone on the back of the head was exposed between the ears. Using hydroxyapatite cement (Mimix bone cement), the entire right occiput was augmented with the material in a putty form and shaped to match the opposite site and allowed to set. Once firm the incision was closed with resorbable sutures. No drain was used.

Occipital Cranioplasty in Child Dr Barry Eppley IndianapolisOnlay cranioplasty in children is as straightforward as it is in adults. The one difference is that choice of cranioplasty material should be as biocompatible to the skull bone as possible which makes the obvious choice of an hydroxyapatite cement. At the bone cement interface, bone will bond directly to the material without any fibrous capsule between them. While the density of hydroxyapatite does not permit bone ingrowth or replacement, bone growth can be expected along the edges of the material and to some extent over the top of it as the child grows. The material will be carried outward as the skull grows through endocranial absorption and ectocranial deposition.

While the decision to undergo skull reshaping in children for a flat back of the head can be viewed as controversial by some, that is a personal decision for parents to make about the need for surgical improvement in their child. From a plastic surgery standpoint, the onlay cranioplasty procedure is safe and effective and has few drawbacks other than a fine line scar in the scalp to perform it.

Case Highlights:

1) Occipital plagiocephaly can be treated at any age by an onlay cranioplasty skull reshaping technique.

2) The cranioplasty material of choice in children are non-resorbable hydroxyapatite cements.

3) Hydroxyapatite cements are the most biocompatible cranioplasty material and will grow with the skull bone as it expands outward.

Dr. Barry Eppley

Indianapolis, Indiana

April 2nd, 2014

Plastic Surgery’s Did You Know? Gender Differences in Buttock Aging

 

Did You KnowButtock reshaping through fat injections or implants has surged in popularity in the past decade. The vast majority of these buttock procedures, to the level of probably 99% of them, are done in women. There may be a lot of cultural and beauty standards for this gender bias but there may also be some age-related reasons as well. In a recent anthropometric study, the age-related changes of the gluteal region were analyzed in women and men from age 15 to 85 years old. Their study results showed that women’s buttocks aged more significantly and earlier with loss of fullness and sagging than in men. The female buttock appears to age faster and suffer more flattening and falling. Men may eventually develop a flat buttocks but it is not associated with much sagging. Such findings support the common plastic surgery procedures today, mainly for women, for buttock augmentation and lifts which either add or bring back the curves to the gluteal region.

Dr. Barry Eppley

Indianapolis, Indiana

March 31st, 2014

Case Study: Breast Augmentation without a Lift in Sagging Breasts

 

Background: One often under appreciated aspect of breast augmentation with implants in some patients is that what will occur is that the existing shape of the breast merely gets bigger. Breast implants do not possess magical properties and they can not cure all ills of one’s breast shape issues. This is why it is critical to carefully assess the breasts before surgery to point out and plan any concomitant techniques to address what an implant can not do or to provide a realistic understanding of what the outcome will be.

Breast Sagging classification Dr Barry Eppley IndianapolisThe biggest patient misconception about breast implants is that they are capable of lifting up sagging breasts. The reality is that nothing could be further from the truth. A minor lifting effect can occur if the nipples are at the level of the inframammary folds. But in real breast sagging or ptosis, where the nipples are below the inframammary folds, breast implants will actually exacerbate the problem not make it better. (type 1 or 2 breast ptosis)

But many women understandably do not want the scars from a breast lift even if they may really need it for their breast augmentation. There is certainly no harm in not doing a breast lift in implant augmentation of sagging breasts as long as one has a full appreciation of what the breasts will look like afterwards. The nipples will not be centered on the breast mound, the implants will look too ‘high’ and the breast tissue may appear to be hanging off of the lower half of the implant.

Case Study: This 26 year-old female came in for breast augmentation after having had two children. She had a grade I/II breast ptosis with a low positioned breast mound and nipples that were just below the inframammary fold. She was offered a vertical breast lift with her augmentation but she did not want the scars that would result from it. She stated she only cared how she would look in a bra or swim suit.

Breast Augmentation without Lift result front viewUnder general anesthesia, she had 550cc high profile silicone implants placed through incisions below her existing folds. The implants were placed in a partial submuscular dual plane location. It could be seen on the operating table that her nipples were not centered on the breast mounds after the implants were placed even though the inframammary fold was lowered as much as possible.

Breast Augmentation without lift result oblique viewHer postoperative result showed what was expected…the implants looked ‘high’ because the nipples and the breast mounds were more on the lower half of the implant rather than centered over it.

Breast Augmentation without Lift result side viewThe relevance of this breast augmentation case is to demonstrate the consequences of not doing a breast lift with implants when one is really needed. One has to choose between a better shaped breast with scars or a scarless breast augmentation result that is far from an ideal shape. The good news is that one can always do a lift later if one eventually decides that scars are a better aesthetic trade-off than this type of augmented breast shape result.

Case Highlights:

1) The shape of the breast, particularly sagging, can adversely affect the outcome of breast augmentation surgery.

2) Contrary to popular perception, breast implants do not have any substantial lifting effect on a sagging breast.

3) The aesthetic tradeoff for augmenting a saggy breast without a lift is a very full upper pole and a low nipple position.

Dr. Barry Eppley

Indianapolis, Indiana

March 30th, 2014

Management of the Step-Off in a Sliding Genioplasty

 

A sliding genioplasty is a well known method of chin augmentation. It is often compared to a chin implant when considering aesthetic changes to the chin as a more natural alternative. But the reality is that its indications for use are somewhat different than an onlay bony augmentation. It is often only used when the amount of chin augmentation is considerable, certain dimensional chin changes are needed (vertical lengthening, width narrowing) or some functional improvement is desired. (e.g.,  lower lip incompetence, mentalis muscle hyperactivity, sleep apnea)

Sliding Genioplasty Dr Barry Eppley IndianapolisWhen a sliding genioplasty is performed, unlike a chin implant augmentation, it creates a sharp step-off between the upper fixed and lower repositioned bony edges. Essentially it is a stair-step effect whose degree and angulation depend on what type of bony movement is done. The bigger the horizontal advancement or the amount of vertical lengthening that is done, the more significant this step-off is.

The step-off in a sliding genioplasty can be more than an anatomic observation. This bony area provides support to the overlying upper soft tissue chin pad and part of the labiomental fold or labiomental sulcus. While it does not provide exclusive support to the labiomental fold, a significant bony step-off from a sliding genioplasty can make it deeper or more indented.

Filling in the sliding genioplasty step-off can be a useful aesthetic maneuver to help make for a more natural chin shape. Numerous alloplastic materials have been advocated for this induced bony contour defect from silicone and Medpor implants to even bone grafts. But getting a good adaptation and adequate fill can be challenging not to mention the alloplastic nature of some of these graft choices.

Hydroxyapatite Granules in Sliding Genioplasty Dr Barry Eppley IndianapolisOne of the best and most historic bony replacement/augmentation methods is hydroxyapatite (HA) granules. Composed of either resorbable or non-resorbable calcium phosphate materials, their granular form allows for a complete fill of a bony defect. Packing granules into a bony defect creates a porous graft that allows for extensive vascular ingrowth and some degree of bony ingrowth or even bone replacement. This is an ideal material for the step-off of a sliding genioplasty which can either be used as a simple fill in or can be packed into an overfilled shape for more of a soft tissue augmentation effect.

While not every bony genioplasty step-off needs to be filled in or augmented, large chin movements can prevent adverse overlying soft tissue effects.

Dr. Barry Eppley

Indianapolis, Indiana

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


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.

Read More


Free Plastic Surgery Consultation

*required fields



Pricing

The cost of any type of elective plastic surgery plays a major role in the decision to undergo the procedure(s).

Get Your Quote Here


My Plastic Surgery Story

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits


Categories