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Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

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

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

October 26th, 2013

Nanofat Grafting for Skin Rejuvenation

 

Fat grafting has been around for over fifty years but has reached present day popularity due to the introduction of liposuction for harvest, droplet injection techniques and the discovery of adipose-derived stem cells. Fat injection grafting is mainly used to create more volume in the face and body for a variety of aesthetic and reconstructive conditions.

As fat injection therapies have evolved, the techniques for injections have gotten more refined using smaller injection cannulas and the placement of smaller fat particles. This is called microfat grafting and is useful for small structures like the eyelids, lips and even large wrinkles or folds. But fat grafting can be taken down to even a smaller level which has been called nanofat grafting. With this method, the fat must first be emulsifed into a pure liquid and then injected with needles or cannulas as small as 27 gauge.

While nanofat grafting is possible, what actually is in the liquid fat and how well does it work? In the October 2013 issue of Plastic and Reconstructive Surgery, the article entitled ‘Nanofat Grafting: Basic Research and Clinical Applications’ provided insights into these questions. In comparing typical lipoaspirate (macrofat), microfat and nanofat, no viable fat cells were seen in the nanograft. Nanografts had a high level of stem cells in which culturing them showed proliferation and differentiation capabilities. Nanofat grafting was performed in 67 cases of facial wrinkles, scars and dark lower eyelids. The clinical results showed good improvement in skin quality without any side effects or complications.

Nanofat grafting is a new concept that takes injections down to small structures and with an injectate which contains few intact fat cells. With a reduced number of viable fat cells, it would have limited use as a volumizing treatment. But as this paper has shown, its use appears to be a treatment option to improve skin quality. (skin rejuvenation) Improvement in skin quality is a well known by product of fat injections and is presumed to occur through increased collagen production and remodeling triggered by the grafted stem cells. Since nanografts have few fat cells in it due to the mechanical preparation process, its cellular component is the stromal vascular fraction of the graft which includes      a substantial number of mesenchymal stem cells.

The location for nanofat grafting is placement into the intradermal level of the skin to improve its quality. The effects of these injections appear to take months to see. Because its effects are probably due to stem cell activity, it may not really be appropriate to call it a fat graft at all. It appears to be more of a poor man’s tissue engineered treatment that is made without expensive and time-consuming equipment. How effective it is can not be completely determined from this one paper, but the concept has merit for more widespread clinical use.

Dr. Barry Eppley

Indianapolis, Indiana

October 25th, 2013

Case Study: Female Jawline Implant Augmentation

 

Background: An underdeveloped jaw or mandible has been historically treated by chin and jaw angle implants. A chin implant enhances the front part of the jaw while jaw angle implants augment the posterior part of the jaw. While these types of facial implants are tremendously effective at augmenting the two obvious prominences of the jaw, they neglect the intervening part of the jawline between the two of them known as the body area.

The mandible is a unique facial bone to aesthetically augment because it is a long curved bone that wraps around the lower face. No off-the-shelf implant currently provides a wrap-around augmentative effect of the entire jawline. Such an aesthetic need exists to make the entire jawline more pronounced and would be of value to make jawlines larger from a side-to-side standpoint. Because silicone is a very flexible material, a wrap around jawline implant could be used for just about any jaw shape and could be inserted through a very small incision.

Case Study: This 33 year-old female was having a skull reshaping procedure and wanted to improve her mildly weak chin as well. She felt her overall jawline was weak and not just her chin area but she did not want her jaw angles to be any bigger or flared. Her horizontal chin deficiency measured only 3 to 4mms in projection.

A new uniquely designed jaw implant was selected for her known as a jawline implant. It is essentially a very long and thin extended chin implant that extended back to the jaw angle area creating a wrap around effect along the inferior border. While the chin projection of the implant was 4mms, it tapered back along the jawline to a 2mm feathered edge. Because of its thin and long design, the stiffness (durometer) of the silicone material was stiffer than that used in other facial implants. That extra stiffness prevents the back tail of the implant from folding onto itself on insertion.

Under general anesthesia, a small 2cm submental incision was made down to the bone. A long extended periosteal elevator was used to make a long and narrow tunnel for the implant back along the lower edge of the jaw (inferior border) to the jaw angles. The implant was folded in half and inserted through the incision with both ends of the implant directed into their respective sides of the tunnels. The implant was easily slide into place and the central chin part of the implant was sutured into place to prevent migration. (although with an implant this long there really could not be an migration or displacement.

The jawline implant offers a new type of jaw augmentation implant that is uniquely different from the chin and jaw angle styles. By making the jawline more distinct and adding some slight width, it makes a more prominent jawline in a subtle but aesthetically pleasing manner. It is not designed to create an overpowering jawline augmentation but a subtle enhancement.

Case Highlights:

1) A more defined and distinct jawline is a desireable feature for both men and women and is the result of a more defined inferior border of the mandible.

2) A jawline implant is different than other jaw implants such as a chin or jaw angle implants as it accentuates the mandibular inferior border from the chin back to the jaw angles.

3) Jawline implants can be used alone to enhance a mildly weak jawline or as an additive benefit to facelift surgery.

Dr. Barry Eppley

Indianapolis, Indiana

October 24th, 2013

Plastic Surgery Product Review: Juvederm Voluma XC Injectable Filler

 

Injectable fillers are the other half of injection treatments (Botox is the other half) that have revolutioned the approach to facial. Evolving from the first FDA-approved injectable filler in 2002 (Restylane), there are now over a dozen different facial fillers from various manufacturers. The latest filler options have become focused on filling a specific type of facial volume indication which is not a surprise as the filler field has become crowded and new product introductions must fill a specific niche to become a used option.

Such is the role that the latest facial filler that has just received FDA approval has. Juvederm Voluma XC (Allergan) is the first and only filler approved to treat age-related volume loss in the cheek. (midface) It has been shown in clinical trials to create a more youthful appearance in the face with results that can last up to two years. The value of this long-lasting but temporary filler treatment is that as people age the cheeks lose volume and sag, creating a midfacial flattening look. Adding back volume with Voluma XC helps restore convexity back to the cheek area, like a poor man’s submalar cheek implant.

Juvederm Voluma XC is made with the proprietary Vycross technology that allows the gel to be injected smoothly and consistently through a needle or microcannula. Like other Juvederm products, it also contains lidocaine which provides a numbing effect during the treatment. Juvederm Voluma XC is not new, it has been used in Europe since 2005 without lidocaine  and since 2009 with lidocaine in it. The potential side effects with its use are exactly like that of any filler, temporary swelling, bruising, and lumps and irregularities.

Juvderm Voluma XC is a hyaluronic-acid injectable filler that can now rival other fillers used for their facial volumizing effects such as Sculptra and Radiesse.

Dr. Barry Eppley

Indianapolis, Indiana

October 23rd, 2013

Skull Dimpleplasty – A Surgical Technique For Correcting Small Skull Indentations

 

The skull develops its shape from a variety of influences including genetics, sutural development, the growth of the underlying brain and external molding forces. While the shape of the skull has recognizeable normal characteristics, it is prone to wide variations in its dimensions and no two people have exactly the same looking head. But, in general, most skulls have relatively smooth convex surfaces.

But not every skull is completely smooth and many people have small lumps and bumps on their skull. Such findings are so common that a whole field of pseudoscience that was very popular in the 19th century, Phrenology, developed around the interpretation of a person’s psychological attributes based on these skull contour irregularities. While Phrenology has long been discredited as having any relevance to a person’s psychological make-up, some of a skull’s ‘high and low’ spots are aesthetically bothersome to some people.

While a skull can have raised areas (e.g., osteoma), it is also prone to indentations or dimples. Skull dimples occur most commonly in the remnant location of the original fontanelles. Fontanelles or soft spots are where open spots existed as spaces between the incompletely formed skull bones in neonates and infants. Everyone at one time has felt the anterior and posterior soft spots on a baby’s head. (and the pulsating beat of the brain) While the anterior fontanelle eventually closes at 9 to 18 months after birth, the posterior fontanelle closes much more quickly within the first few months after birth.

While the soft spot on a baby’s head may make it seem to be susceptible to a potential brain injury because of the lack of bone, the fontanelle is covered with a really tough membrane that is not easily penetrated. But this tough membrane can occasionally impede bone from achieving a normal thickness as it ossifies. This then leaves a small crater or indentation (dimple) where the original fontanelle space was. Why it occurs more commonly at the location of the posterior fontanelle, which closes much sooner, is not known.

Correction of a skull dimple, located at the old fontanelles or otherwise, can be done through a very limited incisional cranioplasty approach. (skull dimpleplasty) It should not be thought of as an injectable cranioplasty per se although the bone cement material is introduced that way. Rather a very small incision, usually 1 to 1.5cms, is made to lift the soft tissues off of the bone to make a pocket for the augmentation or fill-in material. The tissues need to be elevated way around the dimple so that the material can be smoothly contoured into the surrounding normally-shaped bone. Usually PMMA bone cement is used because of its flow characteristics when it is mixed. It is introduced through the small incision down to the bone. Usually 5 to 7 grams of material is needed to adequately fill the bony dimple. The shape of the plug of material is done by pressing from the outside as it cures and gets hard.

Skull dimpleplasty is a very simple and effective skull reshaping technique for small indentations/dimples. It is quick and easy to do and the plug of material is easily pressed flat and smooth over the dimple.

Dr. Barry Eppley

Indianapolis, Indiana

October 22nd, 2013

Plastic Surgery Product Review: Brazilian Butt Lift Shaping Garment

 

The Brazilian Butt Lift  (BBL) is one of the most popular body contouring procedures today. Using the patient’s own fat which is harvested by liposuction and then concentrated, it is injected into the buttocks to increase its size. It is not really a buttock lift per se but one could argue that the increase in buttock size provides a bit of a volumizing lift. Regardless the name and its acronym, BBL, have stuck in the plastic surgery nomenclature.

Once the fat has been injected, there is no consensus as to how to keep fat in the desired buttock position or to help shape the fat-injected buttocks afterward. Most plastic surgeons use a general compression garment that is typically used for liposuction of the thighs and abdomen. It applies a generalized light compression force to the entire buttocks but it is certainly better than no wearing no after surgery garment at all.

But there are very specific types of buttock reshaping garments that are available that apply a circumferential compression around the buttocks, like a circular ring. This would seem to be a better method of force distribution, in theory keeping the fat localized to the desired area of maximal buttock projection. This forced projection is largely negated when one sits down but in a vertical or prone position helps  keep the fat grafts localized. Such garments do the obvious, leave a large hole so that the buttocks is pushed up and out.  These garments are available on eBay or Amazon at prices from 10 to 45 dollars.

While there is no real science behind the concept of shaping the fat-injected buttocks by an external garment, it seems to make sense and will certainly do no harm. Until one day an active buttock reshaping garment becomes available, these passive garments that provide buttock mound protrusion by compressing around it are an inexpensive option to help get the best buttock shape after fat augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

 

October 21st, 2013

Case Study: Lateral Corticotomy Jaw Angle Reduction

 

Background: The frontal view of the face allows one to see its width from the forehead down to the jawline. This width and its proportion to the length of the face helps create an  overall facial shape. It is generally acknowledged that there are seven basic facial shapes which for women an oval shape is more aesthetically desired while for men a more square shape may be preferred.

But to create a slimmer or more oval-shaped face, narrowing of the lower face is often needed. While Botox can be used to reduce the thickness of the masseter muscle, narrowing the underlying bony jaw requires surgery. Most of the width of the bony jaw  is located in its back half, technically known as the ramus of the mandible. Due to the natural divergence of the jawline from the chin on back, the jaw angles make up the widest part of the lower face.

Reduction of the jaw angles is a well known surgical technique that is used for narrowing a wide lower face, most commonly done for Asian facial reshaping. Historically, jaw angle reduction was an amputation method removing the entire angle in an oblique fashion. While that may be effective in some patients, it is often a technique that is overused and can create undesired aesthetic consequences. (tissue sagging, steepening of the mandibular plane angle) This has led to less aggressive techniques where the angle shape is preserved and its thickness is reduced by a lateral corticotomy.

Case Study: This 33 year-old female was having multiple procedures for facial reshaping. One of the changes she wanted to make was a narrowing of her lower face. But she did not want to lose the shape of her jaw angle and did not want a ‘traditional’ jaw angle amputation technique.

Under general anesthesia an intraoral posterior vestibule incision was made on both sides. The bony angles were exposed. Using a handpiece and burr, the cortical bone was shaved down completely to the marrow space, essentially doing a complete lateral corticotomy on both sides.

The two options for jaw angle reduction are very different in the effects they create. A traditional technique amputates the jaw angle, changing the slope of the mandibular plane as it narrows the bigonial width. Conversely, lateral corticotomy reduction preserves the shape of the jaw angle but has a less significant width reduction.

Case Highlights:

1) Reduction of the posterior lower width of the face involves removal of a portion of the jaw angle…if it has adequate flare or bone thickness.

2) Jaw angles can be narrowed by either a full thickness (amputation) or a partial thickness reduction technique.

3) The width of the posterior lower face is a combination of both bone and soft tissue and bone reduction alone does not always guarantee a very visible narrowing effect.

Dr. Barry Eppley

Indianapolis, Indiana

October 19th, 2013

Revisional Rhinoplasty – Prevention and Operative Techniques

 

It is well acknowledged that rhinoplasty is one of the most challenging of all aesthetic plastic surgeries. This translates into a significant after surgery incidence of some level of aesthetic dissatisfaction and nasal airway compromise. Estimates vary but the risk of the need for revisional surgery after rhinoplasty is around 15%. Unfortunately secondary rhinoplasty is not a guarantee of a perfect result either due to the presence of scar tissue and other tissue alterations from the initial procedure.

It is well acknowledged that the best way to avoid the need for revisional surgery is to prevent or avoid the type of problems that lead to it. From that perspective, what are the most common primary rhinoplasty problems? In the October 2013 issue of Plastic and Reconstructive Surgery these issues are addressed in an article entitled ‘Frequency of the Preoperative Flaws and Commonly Required Manuevers to Correct Them: A Guide to Reducing the Revision Rhinoplasty Rate’. In reviewing 100 secondary rhinoplasty patients, the most common reason for surgery was functional in nature with airway obstruction and septal performation. Aesthetic reasons were largely for asymmetries of the bridge, nostrils and tip. Accordingly, the most common secondary rhinoplasty procedure was septoplasty to either improve a breathing issue or to harvest cartilage grafts to address the aesthetic asymmetry issues.

While some may view secondary rhinoplasty patients as difficult and hard to please, the vast majority have legitimate concerns that can be improved with good results as this and other studies have shown. Given that breathing problems are such a common complaint, a variety of preventative manuevers during the initial rhinoplasty can be done. As stated in the article these include the use of spreader grafts, high-to-low nasal osteotomies and partial reduction of the inferior turbinates. The prevention or treatment of common aesthetic deformities can be done with the aggressive use of of dorsal, lateral crural struts and alar rim grafts for prevention of distorting forces during healing and to camouflage structural irregularities.

One of the most basic tenets of contemporary rhinoplasty is to avoid reductive/destructive manuevers and focus more on reshaping the natural cartilage with sutures and the liberal use of cartilage grafts for support. This creates stronger noses that can better resist the inward forces of inspiration and protect against scar contracture afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

October 18th, 2013

Treatment of Injectable Filler Nodules

 

Injectable fillers continue to enjoy a prominent role in aesthetic facial enhancement due to their ease of administration and their instantaneous effects. The most popular and commonly used fillers are hyaluronic-acid based (Juvederm, Restyane for example) with calcium hydroxlapatite (Radiesse) being a more distant second choice. While the occurrence of complications with these FDA-approved fillers is very uncommon, they are not non-existant. As more and more injectable filler treatments are being done, it would be expected that the number of filler-related problems, small as they may be, will similarly increase.

While there are a range of injectable filler complications that can occur (bruising, asymmetry, overcorrection, undercorrection, misplacement, swelling) these are generally temporary issues that are self-solving problems with time. The one more problematic and often not easily solved filler problem is that of nodules or lumps. Persistent lumps could just be just  too much filler or an inflammatory reaction to the filler or a chronic infection as a result of the filler. It is important to first establish what type of injectable filler nodule problem that exists before embarking in treating it. The classification of nodules can be divided into acute (occurring with 2 days of the treatment) and subacute. (occurring up to 2 weeks or more after treatment)

Acute filler lumps that appear right after treatment are most commonly due to a small hematoma. It is a needle that is used for placement, which can transect small vessels, and high injection forces can also cause local bleeding. Such effects are most commonly seen around the eyes and lips where the tissues are thin and highly vascular. An acute lump that may also have bluish discoloration is when a filler lump is too close to the skin. Due to the Tyndall effect, there is a preferential scattering of blue light back to the observer’s eye. These type of filler lumps, which may be aesthetically disturbing, are usually self-solving over several weeks to a month. If the patient wants a faster response, the use of hyaluronidase will enzymatically dissolve the unwanted material if it is a hyaluronic acid-based filler.

Lumps that appear weeks later are either due to clumping of particulated material (Radiesse) or due to some form of reaction or inflammatory response.The key differentiator is whether it is associated with redness, heat and tenderness, all signs of infection. If it is just a benign clump, passing a small gauge needle in and out of the clump (needle dispersion) with the injection of some hyaluronidase will help break it up. When the filler lump is infectious, it should then be treated with oral antibiotics. Because the innoculum is likely staphyococcus from the skin, Kelfex may be sufficient. But if it fails to show a quick response, changing to a flouroquinolone like Cipro may be more effective as it can penetrate resistant biofilm layers better. if it is a growing red lump, needle puncture to provide some purulent drainage may be needed in addition to oral antibiotics. While the risk of infection from injectable fillers is remarkably low, it can still happen. Removing makeup, cleansing the skin and minimizing needle sticks are all good strategies to avoid this potential problem.

Injectable filler lumps are not rare and most are benign and self-solving. But clumping of particulated materials and inflammatory/infected nodules will usually need treatment for resolution.

Dr. Barry Eppley

Indianapolis, Indiana

October 16th, 2013

Case Study: Surgical Rejuvenation of the Aging Mouth

 

Background: Aging affects all parts of the face and the mouth area is no exception. The changes of the lips and the perioral tissues are classic and include thinning of the lips, downturning of the corners of the mouth and the development of vertical lip lines. These central facial aging changes are unaffected by more peripheral procedures like a facelift. Rather they require a direct approach to their treatment and are not uncommonly done as part of a facelift to provide a more complete facial rejuvenation effect.

While injectable fillers are the mainstay of younger lip and mouth enhancements, the older aging mouth is less responsive to just pure plumping effects. It needs more help with actual mini-lifting prcedures that are designed just for the lips.

Case Study: This 62 year-old female was bothered by the constant frown of her mouth and the thinning of her upper lip. While she had always had a thinner upper lip, it had gotten even thinner as she has gotten older. Her goal was not to have really big lips but an upper lip that matched the size of her lower lip. But what really bothered her was the downturned corners of her mouth. This made he look mad all the time when she really wasn’t.

A lip rejuvenation plan was marked out that included an upper lip (vermilion) advancement, corner of the mouth lifts and fat injections into her marionette lines.

Under local anesthesia which included infraobital nerve blocks and direct local infiltration into the upper lip, a 3mm vermilion lip advancement was initially done with making the cupid’s bow area more accentuated. The tail ends of the vermilion advancements were left open in preparation for the corner of the mouth lifts. Corner of the mouth lifts were done by making an outward line of 7mms from the corners toward the tragus and turning that into a triangle as it curved toward open end of the lip advancement. Finally, fat was harvested from her abdomen from inside her bellybutton, concentrated and then injected from the bottom end of the marionette lines upward, placing 4ccs of fat per side.

There are many options for turning an aging or unhappy mouth area into a more rejuvenated one. While the most common technique that comes to mind are injectable fillers, they usually are inadequate for older lip and mouth area as the exclusive treatment option. To make lips fuller or to change the smile line in older patients requires skin removal and lifting techniques.

Case Highlights:

1) Lip and perioral aging is often accompanied by a combined thinning of the upper lip and downturning of the corners of the mouth.

2) Corner of the mouth lifts combined with an upper lip advancement creates a more complete lip rejuvenation effect.

3) Most perioral rejuvenation procedures can be performed under local anesthesia as an office procedure.

Dr. Barry Eppley

Indianapolis, Indiana

October 16th, 2013

The Influence of Breastfeeding on Breast Augmentation

One common question that may women ask when getting breast augmentation is whether the implants will interfere with breast feeding. The answer, whether the implants are placed below or above the pectoralis muscle, is that they do not since either location puts them underneath the breast gland tissue. There is no disruption of the breast ducts or the milk-producing glands by a breast implant.

But another breast feeding concern, since it won’t be affected by the implants, is whether by doing so it will cause increased breast sagging afterwards. According to a paper presented at the 2013 annual American Society of Plastic Surgery meeting this past week in San Diego, women with breast implants should not be concerned that breast feeding will cause a significant change in the appearance of their breasts afterwards.

In a study out of Puerto Rico of 119 women with breast implants who breastfed, they did not see appreciable changes in the appearance of their augmented breasts. Breast measurements were compared between 57 women with implants that did breastfeed to 62 women with implants that did not. The breast measurements were taken before pregnancy and one year after pregnancy or one year after finishing breastfeeding. There were no significant changes in these measurements or in the amount of sagging between women that did or did not breastfed.

Any breast sagging seen was felt to be due to the changes caused by pregnancy not breastfeeding. The cause of breast sagging after pregnancy is due to the hormonal effect that causes breast enlargement by tissue engorgement. Once the hormonal influences are removed (delivery), the breast deflates and sags. (expanded skin but loss of volume) This is the etiology of breast sagging after pregnancy not breastfeeding.

Other breast studies (without implants) have also shown that the cause of breast sagging due to breastfeeding is a myth and not a fact.

This information should help women with breast implants feel comfortable about making the choice to breastfeed and not be concerned that the investment they have made in breast augmentation surgery would be lost.

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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