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.

March 3rd, 2014

Case Study: Rhinoplasty for the Crooked Nose

 

Background: Combination internal nasal surgery to improve breathing and external nasal reshaping is commonly done. Technically this is known as a septorhinoplasty procedure.  While the two nasal surgeries can be done separately and frequently are, one can always influence the other adversely. An overly done rhinoplasty can collapse the middle vault  and narrow the internal valves and cause breathing impairment. An overly aggressive septal removal can result in collapse of the overlying nasal profile.

Nasal Septum in Deviated Noses Dr Barry Eppley IndianapolisNasal deviation is a common aesthetic nasal deformity. Many patients think that if they have a deviated septum that a septoplasty will also correct a crooked nose as well as improve their breathing. The reality is that nothing is further from the truth. When the nose is deviated or twisted, the structural problems are more than just a deviated septum. Almost all of the supporting nasal structures are deviated as well including the nasal bones and the upper and lower alar cartilages in many cases.

Rhinoplasty in the deviated nose is a challenging procedure. Getting a completely straight nose while performing external nose reshaping requires a complete ‘rebuild’ approach from the septum on out.

Case Study: This 47year-old female consulted for a rhinoplasty to reshape her nose. She had a twisted nose and a completely blocked left nasal airway. She had no history of any nasal trauma and her nose had been his way as long as she could remember.

Airway Preserving Rhinoplasty Dr Barry Eppley Indianapolis front viewUnder general anesthesia, an open rhinoplasty approach was used in which the septum was accessed by separating the upper alar cartilages. Grafts were harvested from the septum and it was straightened by releasing its maxillary attachments with multiple scoring of the cartilage. Its caudal end was secured to the anterior nasal spine and bilateral spreader grafts were placed after a hump reduction was done. A columellar strut as placed and the tip cartilages narrowed by a suture technique. The medial footplates were then sutured to the end of the septum to ensure a midline position. The nose was then closed without doing any osteotomies.

Airway Preserving Rhinoplasty Dr Barry Eppley side viewHer three month result showed a straight nose with an improved dorsal profile. Of equal importance, she could breathe better through the left side of her nose.

Rhinoplasty can produce many nasal shape changes by manipulations of the nasal bones and alar cartilages. But when it comes to straightening the crooked nose, managing the septum becomes a critical component of the procedure. It is not only an important source for grafts but must be reshaped and straightened to serve as the central midline support fo the rest of the nose.

Case Highlights:

1) One of the most important steps is any rhinoplasty surgery is to either preserve nasal breathing or make it better.

2) Septal straightening and inferior turbinate reductions are often done in combination with external nose reshaping.

3) Spreader grafts of the middle vault and tip rotation are two rhinoplasty manuevers that can protect or improve nasal breathing.

Dr. Barry Eppley

Indianapolis, Indiana

March 2nd, 2014

Strategies for Successful Liposuction Outcomes

 

Liposuction is the fourth most commonly performed aesthetic plastic surgery procedure in the U.S. as determined by the American Society of Plastic Surgeon’s annual Statistics in 2013. At over 200,000 procedures performed (this estimate is undoubtably low), there is a lot of fat being removed from the face to the ankles. What is unique about body liposuction in particular is the trauma that it induces on broad surface areas of the body.. This makes the issue of safety in liposuction of paramount importance.

Abdominal Liposuction Surgery Dr Barry Eppley IndianapolisThere are some basic principles in performing liposuction that can make for a successful and safe outcome. These include patient selection, intraoperative monitoring, fluid and drug management, contouring techniques and postoperative care.

Many liposuction problems start right at the initial consultation. Many patients that seek liposuction are pursuing it for the wrong reason. They see it as a weight loss method or have unrealistic expectations about what can be achieved. Some of these misinterpretations are created by the very advertising that some doctors do that drive patients in for consutations. Then there is the issue of long-term lifestyle changes, which if not done, may lead to an eventual re-accumulation of the removed fat.

Many liposuction procedures are done under general anesthesia to get the best result and for maximal patient comfort. The anesthesiologist provides fluid management, ensuring that enough intravenous fluid is given to maintain adequate blood pressure but not too much to create fluid overload. This is a delicate balance with the amount of tumescent fluid infused to safely perform liposuction and the amount of fat removed. Whether done under general anesthesia or not, it is also important to know how much lidocaine (and epinephrine) has been infused during tumescent infiltration and that is within safe dosages for the patient’s weight.

Liposuction (Fat Canister) Dr Barry Eppley IndianapolisContouring with liposuction is just as much an art as a science. While patients get focused  on the choice of liposuction technology, there are many other ‘simpler’ intraoperative techniques that are just if not more important. Small cannulas, closer access incisions, cross-tunneling and a bimanual touch technique can help to create a more even removal of fat beneath the skin. But when contour depressions are seen, it is best to try and manage them immediately. Sometimes it requires removal of fat surrounding the depression to smooth it out. But other times it requires the re-injection of some of the removed fat to fill out any contour irregularities.

The only thing that patients can really do after liposuction that could have some impact on recovery and outcome is the wearing of compression garments. The wearing of compression garments for the first 10 to 14 days after surgery can help control swelling and may have some mild shaping effect. Wearing them beyond that is more for comfirt than shaping. Adjunctive measures such as Vanquish and other non-invasive body contouring devices can help smooth out any residual contour irregularities.

Patient satisfaction after liposuction is highly driven by their preoperative expectations, both in their body shape and in the recovery process.

Dr. Barry Eppley

Indianapolis, Indiana

February 28th, 2014

2013 Plastic Surgery Annual Statistics for Cosmetic Procedures

 

Aerican Society of Plastic Surgeons Indianapolis Dr Barry EppleyEvery year at this time, the American Society of Plastic Surgeons releases the annual procedural statistics from the previous year. This is always a good snap shot of the state of the specialty. From a cosmetic standpoint, there were over 15 million  procedures performed in 2013. This includes both invasive surgery, minimally invasive and injectable and laser procedures. This represented an increase of 3% over the number performed in 2011.

Of the 15 million cosmetic procedures, 1.7 million were surgical which was a 1% increase. The top five cosmetic procedures were breast augmentation (290,000, up 1%), rhinoplasty nose reshaping (221,000, down 9%), blepharoplasty eyelid surgery (216,000, up 6%), liposuction (200,000, down 1%) and facelifts. (133,000, up 6%) Breast augmentation has been the leading cosmetic procedure for years. and the silicone implant is now used in the majority of them (72%) compated to saline implants. (28%) The introduction of a more form stable silicone material, shaped or teardrop implants and an increasing interest and use of injectable fat grafting to the breast continues to drive breast augmentation popularity.

Two of the fastest rising cosmetic surgery procedures are buttock augmentation and neck lifts. With over 10,000 buttock augmentations performed last year by fat injections (Brazilian Butt Lift), a 16% increase, changing this part of the body has come a long way from implants that have predated it. Neck lifts continue to increase in popularity as people are focused on this sign of facia aging, with more than 55,000 down in 2013. (up 6%)

The majority of cosmetic procedures were not surgery and consisted of injectable and device-related treatments. The top five non-surgical procedures were Botox and botulinum toxin equivalent injections (6.3 million, up 3%), injectable fillers (2.2 million, up 13%), chemical peels (1.2 million, up 3%), laser hair removal (1.1 million, down 4%) and microdermabrasion. (970,000, 0% change) The popularity of injectable treatments continues unabated and with three botulinum toxin options and nearly a dozen soft tissue injectable filler options, patients have a lot of treatment options from which to choose. In 2013, the hyaluronic soft tissue fillers rose a dramatic 18% from the year before.

Plastic Surgery Statistics 2013 Dr Barry Eppley IndianapolisThese annual statistics show that the demand for plastic surgery remains with small but consistent increases in facial rejuvenation and body contouring. With new products and devices coming out each year, patients get exposed to new options and choices to tackle their aging and body change desires.

Dr. Barry Eppley

Indianapolis, Indiana

February 26th, 2014

Case Study: Submuscular Breast Augmentation in Body Builders

 

Background: Body builders and figure enthusiasts create chest and arm muscular volume and definition by cutting fat and inducing muscular hypertrophy. But what differentiates male and female bodybuilders from a chest standpoint is that females should have a breast mound while men are flat. But due to the regimented stripping of fat as part of their training regimens, many female body builders lose most if not all of their breast mounds.

Breast augmentation in body builders always brings up the issue of the pectoralis muscle and how it will be affected by the surgery. Should the implant go above or below the muscle? Will it decrease muscle function and strength afterwards in any way? How long will working out be delayed?

Placing breast implants above the muscle (subglandular augmentation) would seem to be the most logical implant position given that there would be no interference whatsoever with pectoralis muscle function. Such implant positioning, however, has been shown to have more long-term complications such as implant show, rippling and capsular contracture. Using textured silicone implants, possible even shaped ones so they do not look too round, is a reasonable option. In most cases, it is essentially a skin over an implant result.

Conversely, clinical studies have shown that subpectoral breast implants do not have long-term muscle weakening effects. There is some short-term muscle weakness but that generally fully recovers by 6 to 12 weeks after surgery. An inframammary incision is preferred over a transaxillary approach due to less muscle elevation and a quicker recovery.

Case Study: This 29 year-old female was an avid figure body builder who had lost all of her breast tissue. She already had lost some due to having children and working out vigorously and dropping weight took care of what was left.

Petite Body Builder Breast Augmentation result front view Dr Barry Eppley IndianapolisUnder genernal anesthesia, she had high profile smooth round silicone gel breast implants (275ccs) placed through an inframammary approach. They were put in the dual plane position.

Petite BodyBuilder Breast Augmentation result left oblique viewShe returned to light working out in one week and full working out in two weeks. Her three month result show a fairly round looking result for being partially submuscular but with no breast tissue this was not a surprise. She did not report any loss of muscle strength and change in what she could from a weight lifting standpoint.

Submuscular breast augmentation can be done successfully in weight lifting and fitness enthusiasts. It does not affect the function of the pectoralis muscle and this undoubtably because it is in the dual-plane. In the dual plane location the pectoralis muscle is really partially draped over the implant and its excursive range is unaffected. This makes for no alteration in muscle function beyond the first few weeks due to some discomfort.

Case Highlights:

1) Many female bodybuilders can lose most of their breast tissue due to cutting weight.

2) Subpectoral dual plane breast augmentation can be safely done without any long-term negative influence on weight lifting regimens.

3) With little breast tissue cover, the profile of the breast implants is often fairly discernible.

Dr. Barry Eppley

Indianapolis, Indiana

February 24th, 2014

Case Study: Older Male Gynecomastia Reduction with Nipple Transposition

 

Background: Gynecomastia, the development of breasts in men, is often thought of as a young man’s problem. While hormonal changes certainly set the stage for the emergence of breasts in some teenagers and young men, similar problems of a slightly different nature occur at the opposite end of the age spectrum.

When older men develop what used to be called ‘senile gynecomastia’ due to testosterone decline, it is not the ‘plump’ type of gynecomastia seen in youth. Rather it is a sagging mass of chest tissue in which the nipple and breast mound sags over the inframammary fold. There is a loss of skin elasticity and ligamentous laxity that allows the chest to fall off of the pectoralis muscle inferiorly.

While liposuction is a frequent treatment for gynecomastia reduction, it will not produce the desired result in many older gynecomastias. While some chest volume reduction will be achieved, the skin will not tighten up and the nipple will not be elevated higher on the chest wall afterwards. Some type of skin excisional chest wall tightening is needed.

When a breast lift is needed, men must be treated differently than women. Men can not have the same type of breast reduction scars since there is no mound to hide them when the lift is completed. It is the vertical scar between the nipple and the fold that would be objectionable in men.

Case Study: This 76 year-old man was bothered by the sagging shape of his chest. He did not like his appearance in shirts and felt he needed a ‘mansier’ to really hold his chest up. While he had some excessive breast tissue, his excessive skin was as much if not more of a problem.

Gynecomastia Reduction with Nipple Transposition markings Dr Barry Eppley IndianapolisPrior to surgery, his existing inframammary fold was marked as well as around his areolas. An elliptical excision pattern was then marked from one end of the inframammary fold to the other going above the nipple. Under general anesthesia, a tumescent solution was infiltrated into each side of the chest. Using power-assisted liposuction, 200cc of fat and breast tissue was aspirated from each side. The upper and lower ends of the horizontal excision pattern was incised as well as around the areolas. The intervening skin was de-epithelized. An upper chest skin flap was raised up near the collar bones on each side. The thinned out breast mound and nipple was then lifted as the skin edge of the raised chest flap was brought down over it. The new position of the nipples were marked and the overlying skin removed. The nipples were brought through and the circumareolar and inframammary skin edges were then closed to complete the reduction. The nipple transposition eliminated any need for a vertical scar.

Older Male Gynecomastia Reduction with Nipple Transposition front view Dr Barry Eppley IndianapolisOlder Male Gynecomastia Reduction with Nipple Lifts result Dr Barry Eppley IndianapolisHe had drains that were removed two days later  and the incisions remained taped for ten days as he wore a circumferential chest compression wrap. When seen at six weeks after surgery, his chest was flat and the nipples in a much more uplifted position. It would take another 3 to 6 months for the scars to completely mature and fade.

Gynecomastia Reduction and Nipple Transposition result side viewFor the man who has significant chest sagging and requires a breast lift, gynecomastia reduction with nipple transposition creates an acceptable location of the scars.

Case Highlights:

1) The older male patient often develops chest sagging that is difficult to hide and not cured by exercise.

2) With loose and inelastic skin due to age, liposuction does not produce a satisfactory gynecomastia reduction for many older men.

3) Gynecomastia reduction with nipple transposition is the most effective chest reshaping method for the older male with ‘man boobs’.

Dr. Barry Eppley

Indianapolis, Indiana

February 23rd, 2014

Strategies for Successful Buttock Implant Augmentation

 

While implants are used all over the body from the breasts to the calfs very successfully, their use for buttock augmentation is associated with a more checkered experience. Not that implants anywhere can’t be associated with complications, but buttock implants carry a disproportionate amount of criticism. This is partially due to the availability of fat grafting as a buttock augmentation method that doesn’t carry those same risks. It is also because the buttocks are associated with a unique set of recovery issues.

Buttock Implant Sizes Dr Barry Eppley IndianapolisThe successful use of buttock implants for augmentation depends on three critical issues, implant location, implant size and managing patient expectations. Errors in any of these three areas will result in either a postoperative complication or an unhappy patient even if no postoperative complication has occurred.

Intramuscular Buttock Implants Dr Barry Eppley IndianapolisButtock implants can be placed either above the muscle (subfascial) or into the muscle. (intramuscular) While surgeons can place them in either tissue plane, the subfascial location is technically easier to do, has an easier patient recovery and permits implants of almost any size to be placed. However, it is associated with a much higher rate of complications including seroma, infection, implant show, encapsulation and buttock deformity. While the intramuscular location is more technically demanding, has a longer recovery and allows only smaller implants to be placed, it results in a much lower number  of complications. With rarer exceptions, buttock implants should be placed in the intramuscular location.

Buttock Implant Surgical Technique Dr Barry Eppley IndianapolisWhen large buttock implants are placed in the subfascial plane, many will eventually migrate inferiorly toward the lower gluteal crease and often not very symmetrically. Conversely, intramuscular implants do not migrate and remain where they are placed as the tight muscular pocket holds them firmly and permanently in place. However the intramuscular pocket only allows smaller implants to be used, usually not bigger than 350cc in volume. In smaller women, volumes of 250cc to 300cc are more appropriate.\ Bigger implants than this volume make it impossible to close the muscle layer over the implant which is crucial to the success of the intramuscular location.

Between the intramuscular location and the size of the implants, patients opting for buttock implants must have realistic expectations. They will not get large or massively sized buttocks and the volume obtained is going to be in the upper half of the buttocks. This makes the best candidates for buttock implants as thin or lean women who do not have enough fat for the Brazilian Butt Lift option and can accept a modest increase in buttock size.

If properly done in the right patient, buttock implants can have very similar and success rates as that of the breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

February 23rd, 2014

Tracheal Shave Neck Contouring

 

The reduction of a prominent Adam’s Apple through a procedure known as a tracheal or laryngeal shave has been in the news lately. Former Olympic Gold Medalist Bruce Jenner has recently made headlines for purportedly undergoing the procedure and the tabloids have suggested that he may be in a transitional state to becoming a women. While I have no idea about whether he has that procedure and his motivation for doing so if he had, invariably a tracheal shave is almost always associated with facial feminization surgery. FFS()

The reality is, however, that tracheal shaves are not done exclusively in FFS. As many non-transgender patients, usually men, have them done as often as transgender patients. I have men with very large laryngeal prominences that have trouble buttoning a shirt or wearing a tie. Most are just bothered by this large unnatural looking projection in their neck. Less frequently, women may have it done for the same aesthetic concerns although their natural hormonal levels usually preclude it from ever developing that large.

Tracheal Reduction Indianapolis Dr Barry EppleyThe biggest challenge in tracheal shaves is to get it completely eliminated and the neck perfectly smooth/flat. This can be particularly difficult in very thin patients with large laryngeal prominences. In some patients getting a perfectly smooth neck with no bump may not be possible. There is balance between how much can be removed and avoiding entering the airway.

How aggressive one can be with tracheal shave reduction depends on how they balance the risk factors of entering the airway and destabilizing the larynx and causing voice changes. Some prefer to do it under fiberoptic larnygeal visualization of the vocal cords  and the anterior mucosal wall. Others use conservative intraoperative judgment and gently dissect off the mucosal lining and thyrohyoid ligament from the inner cartilage surface of the laryngeal prominence of the thyroid cartilage to allow for maximal reduction. Revisions of tracheal shaves are probably best done under visualization of teh airway.

Direct Tracheal Reduction Dr Barry Eppley IndianapolisThe surgical approach to a tracheal shave can be done either directly from more remotely. Most every one has some semblence of a horizontal skin crease near the laryngeal prominence and this can be used for direct access to the reduction As long as the incision does not exceed 2.5 to 3 cms and with good closure techniques, it can heal imperceptably.  The other approach is to make the incision high up under the chin in a submental neck crease. It is harder to get a good reduction this way but it can be done.

Most laryngeal prominences can be reduced as the same implies (tracheal shave) by using           a scalpel to shave the prominences down. However, some patients will have stiffer cartilage that may be partially ossified. In these cases, scalpel will not make a dent in it. This usually occurs after some shaving has been done and the stiffer cartilage is revealed underneath. A handpiece and a small rotary burr can complete the reduction is a controlled manner.

The vast majority of tracheal shaves patients are satisfied with their initial operation. It does take a few months for all the laryngeal swelling goes down to see the final result. Some do wish that more could have been removed but accept that there are limits based on their anatomy and remain satisfied with an uncomplicated and improved neck result.

Dr. Barry Eppley

Indianapolis, Indiana

February 23rd, 2014

Nasal Surgery in Children and Young Teens

 

Nasal surgery has traditionally been a procedure that has been reserved for later teenagers and adults when the development of the nose is complete. Since the septum of the nose is the main driving force for the growth of the nose, any manipulations were felt to result in subsequent deviations or arrest of nasal development.

But to those plastic surgeons that treat cleft nasal deformities, we know that is not absolutely true. Many septal and nasal tip deformities are treated at very early ages without observable long-term growth disturbances. While these are noses that are not completely normal and have their own built-in abnormalities, long-term follow-up into adulthood (which is common in cleft patients) does not show any signs of growth arrest.

Corrective Nasal Surgery in Younger Patients Dr Barry Eppley IndianapolisIn the Online First edition of the February 2014 issue of JAMA Facial Plastic Surgery, an article appeared titled ‘Corrective Nasal Surgery in the Younger Patient’. In this paper, the authors reviewed their experience in corrective nasal surgery in pediatric patients. A total of 54 patients (teenage males younger than 16, females younger than 14) who had either septoplasty or corrective nasal surgery over a 16 year period were reviewed. The most common reasons for surgery were posttraumatic deformities (36) and significant airway obstruction. (48) Five patients underwent a staged  procedure and no patients had any revisions for unsatisfactory results.

The authors conclude that children with nasal airway obstruction can safely have nasal corrective surgery before the nose is fully developed. They emphasize the preservation of normal structures and the judicious use of grafts. The key being is that there is no reason that nasal surgery can not be done on children and teens as long as there is a good reason (significant airway obstruction) and that radical removal of septal and turbinates is not done. More elective external nose reshaping (rhinoplasty) should still be reserved untila age 14 and older.

Dr. Barry Eppley

Indianapolis, Indiana

February 22nd, 2014

Case Study: Sliding Genioplasty For Increased Projection and Vertical Shortening of the Chin

 

Background: Chin deficiences are common and are usually satisfactorily treated by an implant augmentation method. While implants are good for mild to moderate short chin problems, they often are not adequate for a chin that has a more significant horizontal deficiency that is accompanied by other dimensional abnormalities.

Sliding Genioplasty Indianapolis Dr EppleyMoving the symphysis of the mandible, known as a sliding genioplasty, is the other method of chin augmentation. It is not nearly as often done as chin implants being more invasive with a higher potential morbidity and longer recovery. It is frequently done as a complementary procedure in orthognathic surgery given that other jaw bones are being moved as well. But in the patient, a sliding genioplasty can outperform an implant by producing a better aesthetic result.

The sliding genioplasty has one dimensional advantage historically over an implant, its ability to change the vertical dimension of the chin. It can lengthen the vertical height of the chin as well as shorten it with any degree of horizontal advancement. While newer styles of chin implants now make it possible to lengthen the chin, no implant will ever be able to shorten the vertical height of the shin.

Case Study: This 18 year-old young man had a short chin that he wanted to improve. His chin was vertically elongated due to the shape of the mandible (lower jaw) to which it is attached. He also had some lower lip incompetence and a hyperactive chin ad due to excessive mentalis muscle activity.

Sliding Geniop[asty intraop technique Dr Barry Eppley IndianapolisUnder general anesthesia, an intraoral incision made to expose the chin. Using a reciprocating saw, an angled osteotomy cut was made staying 5mms below the mental nerves where they came out of the bone. The chin segment was downfractured and brought forward 10mms and vertically shortened 3mms by the bending of the chin plate fixed to the stable bone above and the mobilized bone below with screws. The mentalils muscle was then put back together and the mucosa closed.

Sliding Genioplasty result side view Dr Barry Eppley IndianapolisSliding Genioplasty result front view Dr Barry Eppley IndianapolisAfter surgery he shows an improved chin position in profile to the rest of his face. His chin was also vertically shorter which was particularly apparent in the front view, shortening the excess length of his whole face.

The sliding genioplasty can do much more than just increase the horizontal projection of the chin. Attention needs to be paid to the other dimensions of the chin and how it relates to the rest of the face. Vertical shortening is the one dimensional change that only a bony genioplasty can create. Many very short chins have an elongated chin due to the backward rotation of the mandible. Vertical shortening can be created by the removal of a wedge of bone or by how the chin step plate is bent and positioned on the bone.

Case Highlights:

1) The sliding genioplasty is a versatile procedure that can not only augment the chin horizontally but also change its vertical height as well.

2) The angle of the osteotomy cut and the fixation plate used in a sliding genioplasty can lengthen or shorten the vertical height of the chin as it comes forward.

3) A sliding genioplasty can be done to bring the chin forward and shorten it vertically to keep the lower third of the face in good balance with the upper two-thirds.

Dr. Barry Eppley

Indianapolis, Indiana

February 21st, 2014

Case Study – Custom Temporal Implants for Head Widening

 

Background: The head has a wide variety of shapes and sizes. Like the face, there are  certain head shapes that are more pleasing than others. While one knows intuitively whether they like their head shape or not, there are certain measurements of height and width of the head that can help classify its beauty or conversely its degree of deformity.

Head Measurements Dr Barry Eppley IndianapolisHead and face measurements and their ratios have been studied for over 100 years in a field of scientific study known as anthropometry. Classic anthropometric measurements of the head are its length, width and cephalic index. The length of the head (front to back) is measured from the midpoint of the brow just above the nose back to maximal projecting point of the back of the head. The width of the head is from a point just above the ears from one side to the other. Taken together the cephalic index is derived which is obtained by taking dividing the width of the head by its length which creates a percent ratio. This number is almost always less than 1 since most normal human skulls are longer than they are wide. Based on their cephalic index, head shapes have been historically divided into three main types; long-headed (dolichocephalic, > 80%), medium-headed (mesocephalic, 75% to 80%) and round-headed (brachycephalic, < 80%)

The dolichocpehalic head is one that has a narrow head width. (which is compensated for by an increased head length) But there are certain head shapes that are narrow in their bitemporal width but do not have an increased cranial length. Their mid-temporal region slants inward as it ascends upward to the top of the skull rather than having a more aesthetically pleasing convex shape on the side of the head.

To date, there has not been any known method to safely and easily create aesthetic augmentation for increasing the width of one’s head should their bitemporal width be too narrow.

Case Study: This 35 year-old young man did not like the narrow width of his head. He felt his head was too narrow above the ears and it slanted inward rather than outward. This made his head ‘too small’ and disproportionate for the rest of his head and face shape. He wanted a wider head but did not want any visible scars in doing so given his close cropped hair.

Custom Temporal Implants for Head Widening Dr Barry Eppley IndianapolisWhile a 3D CT scan would have been ideal to make his custom temporal implants, he wanted to forego that extra expense. Using a standard male skull model, implant designs were done in silicone elastomer putty by hand with dimensions of 10 cms long, 8cms high and 7mms thick at its central location. The edges were made paper thin to have a smooth implant transition. The handmade temporal implants were converted into a medium durometer medical grade silicone implant and sterilized.

temporal implant size dr barry eppley indianapolisTemporal Widening Implants Surgical Placement Dr Barry Eppley IndianapolisUnder general anesthesia, skin incisions were made on the back of the ear in the depth of the postauricular sulcus. Dissection was carried down to the fascia and then superiorly under the lower edge of the temporalis muscle. Wide submuscular elevation was done over markings for the implant location that were made prior to surgery. The temporal implants were then rolled and inserted through the small incision and all edges unrolled once inside. The implants were then secured to the underlying bone at its lower edge with two 1.5mm titanium screws. The incision were closed in multiple layers, re-establishing the postauricular sulcus by dermal sutures to the fascia.

While he had some moderate temporal swelling after surgery, his pain was minimal. He had little recovery other than some swelling that resolved in a few weeks. His head width was instantly changed into a more convex shape which was very pleasing, adding 1.5 cms of bitemporal width. (Due to patient privacy, he did not want his before and after pictures published online. However he is willing to have them sent to anyone that wants to view them privately. You can request his before and afters by contacting me at info@eppleyplasticsurgery.com)

This type of temporal implants provide increased width and convexity for the narrow head. While custom temporal implants can be made from a  patient’s 3D CT scan, the relative flat bony surface of the mid- and posterior temporal region makes a semi-custom approach a good treatment option. This new type of skull implant design provides another option in skull reshaping/augmentation that provides a different type of temporal augmentation that smaller more anterior-based implants for the non-hair bearing temporal hollow.

Case Highlights:

1) A narrow head is usually due to a bitemporal width reduction of the skull and/or muscle.

2) Custom temporal implants can be made to increase the bitemporal width from 5mm to 7mms per side.

3) Large custom temporal implants can be discretely placed through incisions on the back of the ears.

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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