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.
Background: The nose is made up of many angles, lines and shapes and represents the most aesthetically complex structure on the face…despite its proportionately small size. How all of these various geometries (subunits) fit together changes based on what view or angle that the nose is being assessed. The most basic of all these nasal aesthetic considerations is that of the dorsum and is one of the most commonly manipulated and requested nasal features.
The dorsum is a central subunit of the nose that extends from the frontonasal angle superiorly down to the tip. In the front view it has aesthetic or side lines that create a smooth flow, or lack of the flow, down the length of the nose connecting the inner brows into the tip. In the side view, and a view that is of highest significance to patients, is the dorsal line. This profile line of the nose is a dominant aesthetic feature and has long been one of the most basic motivations for having rhinoplasty surgery as well as how the result is judged.
The dorsal line of the nose is gender specific. Man desire a straight or even the persistence of a small hump at the osteocartilaginous junction. Conversely women either prefer a straight dorsal line, or more commonly, a dorsal line that has a slight concavity to it. Men almost never want such a dorsal line shape.
Case Study: This 33 year-old female wanted to change the shape of her nose. She had a slight nasal hump and a tip that had too much projection. The shape of her nose from the side profile was her most important motivation for having the surgery.
Under a general anesthesia an open rhinoplasty approach was done. The small osteocartilaginous hump was shaved down and smoothed. Her nasal tip cartilages were shortened and narrowed by excision and suturing techniques. Shortening the nasal tip also created the need for further reduction in the height of septum along the middle vault.
Her six month postoperative result showed an improved and more ‘feminine’ dorsal line with a tip that has a better length for her nose. Her dorsal line had the requested concavity or swoop between the forehead and the nasal tip. The columellar scar from the open approach had healed to the point that it could not be seen.
Why is it that women prefer such a nose shape? While fashion and celebrities help drive many a facial look, the desire for a small and perkier nose is a decided sign of femininity. It is also the antithesis of aging…it is a sign of youth and ‘cuteness’.
The desired profile result for a female in rhinoplasty is almost always different than that of a male.
Many women desire a dorsal line profile that has a slight concavity or swoop to it.
Obtaining a swoop to the dorsal line is also highly influenced by the degree of tip rotation and/or shortening.
Surgery for vertical orbital dystopia always includes augmentation of the orbital floor. Most of the time the inferior orbital rim is lower as well and needs to be concurrently augmented. Various materials have been used for orbital implants from bone grafts to numerous synthetic implants. In the ‘aesthetic’ orbital dystopia patient (4mms or less of horizontal pupillary discrepancy) the use of bone grafts is not very appealing.
The ideal method to augment the orbital floor and lower rim is to make custom implants from a 3D CT scan of the orbits. With this technology the exact amount and location of orbital floor and rim augmentation can be determined and made before surgery. This obviates any need for intraoperative fabrication of the implants.
Beyond the use of preoperatively fabricated implants, various materials offer intraoperative workability. One of my favorite implant materials for the orbit is that of ePTFE. Originally known as Goretex, it comes in sheets of various thicknesses that are easily cut and molded to any surface. Composed of a fluorine-based material that is both very smooth and non-reactive, its flexibility and adaptability make it ideal for the complex contours of the orbit.
ePTFE sheets of 2mm thickness can be layered and adapted to the orbital floor and inferior orbital rim as needed. It is a good idea to secure the material to the orbital rim with several micro screws to make sure it lays flat and is as non-palpable as possible through the thin tissues of the lower eyelid.
Correction of the sagging breast with various breast lift procedures is an important part of breast rejuvenation surgery. Many different types of breast lift procedures have been described over the past century and all involve the use of skin removal and breast envelope tightening to create their effects. Unfortunately the thin breast skin is well known to stretch out and does not usually do a good job of maintaining the lifted breast by itself.
Adding to the armamentarium of the plastic surgeon for breast lift techniques has been that of parenchymal sculpting. This is where the breast tissue itself (not the skin) is reshaped and lifted back up onto the chest wall and secured. This adds to a breast lifting effect and helps to take some of the necessary support off of the tightened breast skin. But often breast skin tightening and parenchymal sculpting still does not provide pleasing long-term results.
A more recent innovation and breast lifting technique has been the implantation of various synthetic meshes. By creating a sling across the lower pole of the breast an additional layer of support is added which theoretically aids the lifted breast long-term.
In the January 2017 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘Use of Poly-4-Hydroxybutyrate Mesh to Optimize Soft-Tissue Support in Mastopexy: A Single-Site Study was published. Over a two-year period, 11 consecutive patients underwent a breast lift with the placement of Galaflex mesh across the lower pole. 3D scans were done for postoperative assessment out to one year after surgery.
There were no complications or infections in the study. Postoperative breast settling occurred between 1 and 3 months after surgery with lower pole stretch of 5% and an average of 8mms increase in the nipple to inframammary fold distance. No significant change occurred from 3 to 12 months after surgery as measured from the sternal notch to inframammary fold distance.
Similar to repairing a hernia, the use of mesh is breast surgery is to reinforce weak tissue. Galaflex is a unique and newer synthetic mesh. It is composed of poly-4-hydroxybutyrate polymer which is a high-strength and resorbable monofilament fiber. It maintains its initial strength out to 3 months after which it remodels and is replaced by collagen (scar) by one year after surgery. The fact that it is resorbable and replaced by one’s tissues is an appealing feature, particularly in the thin lower pole skin of the female breast.
More clinical work is needed to determine the longer term results of Galaflex in breast lift surgery. But the concept remains very appealing has the lifted breast is not very resistant to the effects of gravity.
Dr. Barry Eppley
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Browlift surgery is done by a variety of techniques. Most commonly it is performed from above lifting the brows using either an endoscopic, pretrichial, coronal or mid-forehead incisional approaches. Less commonly it is done from below with a transpalpebral technique pushing up the brows from below and securing with a reorbable Endotine device.
The remaining browlift technique is a direct one with the brow lifted through skin excision right above the brow at the superior hairline. Undoubtably it is the most effective because it attacks the brow position and shape directly, giving maximum control over brow shape and the amount it is lifted. While effective the direct browlift is the least commonly used technique due to visible scar line concerns.
In the March 2017 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows’. In this paper, the authors described their experiences with a direct brow reshaping technique either done alone or in conjunction with blepharoplasty and facelift surgery. A total of 212 patients underwent a direct brow lift procedure. All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results.
There were no major complications. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS.
The authors state that a misconception of the direct browlift procedure is that they create visible scars. With good incision placement, limited undermining, and presurgical use of Botox application, they have found that the direct browlift does not create visible scarring and is the easiest, most precise, and most reliable procedure for brow shaping. It is also the only technique that enables precise correction of minor brow asymmetries.
Dr. Barry Eppley
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Background: One of the many head and neck features that are distinctly masculine is that of the thyroid cartilage or Adam’s Apple. A prominent thyroid cartilage creates a distinct bump in the neck that is associated and aesthetically acceptable in men. While it is often reduced in facial feminization surgery as a tracheal shave procedure in the male to female transgender patient, the reverse has not yet been described.
How to build a more prominent thyroid cartilage has only recently been described for masculinization in a female to male transgender patient. In this solitary description onlay cartilage grafts from the rib were used for tracheal augmentation. Since the Adam’s Apple is a cartilaginous structure it is logical that cartilage grafting would be an effective technique.
But not every such patient may want a rib graft harvested for a tracheal augmentation procedure. Like much of the face, one wonders if an implant can not be effectively used instead of a cartilage graft.
Case Study: This 35 year-old make wanted to improve the shape of his chin and neck. He had a mild short chin, submental fullness and a smooth neck contour. He had a first stage procedure of chin augmentation and a submentoplasty (liposuction and direct defatting with muscle plication) Afterwards he inquired about making his Adam’s Apple more prominent.
In a second procedure the trachea augmentation was planned using a Medpor nasal implant. The shape of the nasal implant is like a saddle (inverted v) which seemed like it would create a tracheal prominence and could be secured onto the front edge of the tracheal cartilage. A v-shaped notch was made in its upper portion to replicate the natural shape of the thyroid cartilage. Medpor nasal implants come with inserts to place under it for increased augmentation which was also done in its use as a tracheal implant. This gives it more outward projection from the anterior surface of the natural thyroid cartilage. Through a small skin incision, the synthetic framework was sutured to the cartilage, the overlying skin flap of fat (to allow more of the framework projection to be seen) and the skin closed.
The combination of chin augmentation, submental reduction and tracheal augmentation produced a more masculine lower face/neck profile. Tracheal augmentation can be done successfully using a properly shaped synthetic implant. The material composition is not an important as its ability to be shaped and secured to the natural thyroid cartilage base.
1) A prominent thyroid cartilage is a male characteristic.
2) Masculinization of the neck can be done by tracheal augmentation.
3) A synthetic tracheal implant can be used to create more projection of the upper V
Jaw angle implants are one of the most unique facial augmentation techniques given its posterior jaw location. Placed under the thick masseter muscle and having a remote and limited access to do so from inside the mouth, the placement of the implant on the exact and symmetric position on the jaw angle bone can be challenging. This is made even more challenging with new implant styles such as the vertical lengthening jaw angle implant in which a portion of the implant is deliberately designed to sit off the lower edge of the bone.
Beyond intraoperative implant positioning concerns, there is also the potential for the implant to move from its desired position. Such implant displacements always occur in an anterior and superior towards the location of the vestibular incisions. Undesired implant movements naturally occur towards the direction in which they were inserted.
To prevent jaw angle implant displacement, screw fixation is almost always used. Over the years I have developed a screw fixation technique that is both reliable and rapid to perform. Trying to insert screws from inside the mouth is both difficult and cumbersome to perform. What works best is a percutaneous technique.
Using a 1.5mm screwdriver, it is inserted through a small 3mm skin nick through the masseter muscle in a perpendicular orientation to the bone’s surface. Once inside the implant pocket it is turned and pointed out of the mouth. A self-tapping screw is placed on the screwdriver blade which is self-retaining. The screwdriver is pulled back into the mouth and turned towards the bone where it its inserted through a superior edge of the implant and driven into the bone. This same technique is repeated for as many screws as one needs to place for optimal implant security. (I have never placed more than two screws
With this jaw angle implant s crew fixation technique, which takes just a few minutes to perform for both sides, one can be assured that the implants will not shift from where they were positioned on the bone.
Background: There are a wide variety of congenital ears deformities that involves either deformed or missing natural cartilage structures of the ear. One such well known deformity is that of the Stahl’s ear. This consists of an ear that has a pointy shape due to an extra fold or third crus in the scapula. It is often referred to as a Spock part in reference to the Star Trek TV character.
Stahls’ ear is primarily caused by the ear cartilage being misshapen. The upper ear usually has two distinct folds known as a superior and inferior crus. But in Stahl’s ear a third crus or fold occurs. This causes the outer rim of the upper ear to fold inward giving it a pointed shape.
If recognized very early after birth, external ear molding devices (e.g., Earwell) can correct the misshapen ear as the young ear cartilage is very flexible and moldable. But once one passes six to weeks after birth the ear loses its responsive to external molding forces and surgery becomes the only treatment option.
Case Study: This 12 year-old male had misshapen ears that he disliked. The upper outer helical rim was bent over or folded in. This created a pointed shape to his upper ears. He had been given the diagnosis of Stahls’ ear although it was not a classic presentation of it.
Under a general anesthesia an incision was made on the back surface of the ears. This allowed the helical rim skin to be dissected off the cartilage and expose the upper ear cartilage shape over the deformed area. Radial cuts were made in the cartilage to allow it to unfurl and create a more defined outer helical rim. To support this new shape a cartilage graft from a small piece of rib #9 was used by suturing it on the inside of the newly formed helical rim. On the right ear a small wedge of cartilage and skin was removed to bring down the height of the helix.The skin was then pulled back over the reconstruction and closed with dissolvable sutures.
His immediate intraoperative result showed improvement in the shape of ear through recreation of a more defined outer helical rim. While many techniques for Stahl’s ear correction have been described they all rely on innate cartilage reshaping alone. Add a small cartilage graft can help support these cartilage reshaping efforts.
Stahl’s ear is a congenital deformity marked by an abnormal fold in the upper ear which makes it pointy.
Reconstruction they deformed upper ear requires cartilage reshaping which often requires the use of a cartilage graft for support.
A small piece of rib #9 can be used for a strong and curved cartilage graft.
The most common method of permanent midface augmentation is that of the cheek implant. Cheek implants have been around for decades and have evolved into a wide variety of styles and sizes. Their fundamental designs have been to augment the prominence of the cheek bone (malar region), the underside of the cheek bone (submalar region) or both. (combined malar-submalar shell or midface implant).
Despite being an adjoining anatomic region to the cheeks and having a smooth skeletal connection, the infraorbital region (undereye area) has been relatively neglected. While there are tear trough implants that can augment the front of the lower eyelid rim, they do not create a smooth and seamless flow into the cheeks nor do they sit on top of the infraorbital rim and increase its vertical height.
The combined infraorbital rim-malar implant augments the anterior cheek (malar region) and the infraorbital rim. For those patients that have a tired look due to an infraorbital-malar skeleta) deficiency (undereye hollows), a unified one-piece implant can be a good solution. It provides a smooth connection along the lower orbital rim into the cheek and provides a more complete correction of the undereye hollow problem. It is best placed through a lower eyelid incision to get optimal fit along the infraorbital rim which is best done from a superior approach.
While there are numerous injectable materials to fill in undereye hollows, which can be very effective for many patients, an implant can provide an alternative treatment option. But not just any implant design will do and there are no standard undereye hollows implant designs currently available. This special design of mine, technically known as the infraorbital-malar design or undereye hollows implant, can provide an effective and permanent option in the properly selected patient. It provides a more complete correction of the underlying skeletal cause of undereye hollows.
Background: The facelift is a well known surgical rejuvenative procedure that primarily creates a smoother jawline and a more defined cervicomental angle. For some facelift patients the addition of a chin implant, if their chin is short, helps improve the jawline by adding increased projection at its anterior edge. This is why many facelifts particularly in women also include a chin augmentation.
While chin augmentation provides an aesthetic benefit to the front end of the jaw during a facelift, the rest of the jawline remains neglected. Some aging patients have weak or high jaw angles. Pulling the facial skin back up and over a weak posterior jaw angle fails to make it more defined. It often only gives it a sweeped look from the skin pull.
Like chin implants, jaw angle implants have a role to play in facial rejuvenation and facelift surgery. Their only drawback is that they will cause a moderate amount of facial swelling over the posterior part of the face during the early recovery period. Good compression facial dressings during the first few days after surgery is very helpful in this regard.
Case Study: This 68 year-old female wanted a lower facelift to remove loose skin along the lower part of her face and give her a more defined jawline. But she had a high and ill defined jaw angle area and opted for the placement of jaw angle implants at the time of her facelift.
Under a general anesthesia and through an intraoral approach, small vertical lengthening jaw angle implants were initially placed. Thereafter a lower facelift was performed with SMAS plication. Her long-term results show improved jaw angle definition and a well defined jawline from chin back to the ear.
Like chin implants, jaw angle implants are aesthetically beneficial in a minority of facelift patients. But in the properly selected patients and in thinner faces, they can add bony definition of the lower face which has a distinct rejuvenative facial effect.
Augmentation of the jawline at the time of a facelift or after has long been recognized as an aesthetic benefit.
Creating a more defined jaw angle builds up the back part of the jawline.
Most jaw angle enhancements in aging require a vertical jaw angle implant style.
Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.
The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.
While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.
Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.
Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.
A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.
With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.
Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.
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.