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It looks like Botox just smoothed the largest wrinkle it has ever seen. Calling it a wrinkle might be an understatement, a better description would be a very deep furrow. News from today reports that Allergan, the manufacturer of Botox the world’s number one wrinkle reducer, has agreed to pay $600 million to settle a years-long federal investigation into how it marketed its top-selling drug.
The company says it will plead guilty to a misdemeanor charge known as misbranding. This charge is based on claims that the company deliberately marketed to doctors on the use of Botox for non-FDA approved uses starting in 2000. Such unapproved uses included the treatment of headache, muscle pain, spasticity and cerebral palsy. It will cost the company $375 million in connection with that plea and an additional $225 million in civil fines related to the investigation, although the company denies any liability in that regard.
While this is a whopping fine for sure, it is well in line with such plea agreements that have been metered out against other major drug manufacturers in recent years. There is some supposition, probably for good reason, that the company agreed to settle as it is awaiting FDA approval for the treatment of migraines which is reported to be worth $1 billion in sales annually.
As a plastic surgeon and provider of Botox treatments, do I think the company did anything wrong? At the patient care level, I would have had no indication that these alleged practices were ongoing as there were never apparent to me. I suspect that the company got overenthusiastic and even greedy as a monopolistic provider of this type of drug. It has never had any competition until just last year. The FDA has rules for marketing and the company obviously transgressed them.
But the reality is Botox is one of the most used drugs when it comes to off-label or unapproved uses. While it is not magic pixie dust, it has been shown to be useful for a wide variety of neuromuscular uses. I regularly use it in the treatment of migraines, masseteric hypertrophy and myofascial facial pain, all with significant relief and results. The ‘problem’ is that Botox appears to be good for a lot of difficult medical conditions. Because it works it becomes highly used for non-FDA approved indications. As a physician that is within my province to make that judgment. The company, however, does not have that leeway as it is not in the business of practicing medicine.
Some patients will undoubtably wonder if this massive fine means the product is tainted or unsafe. There is nothing wrong with Botox as a drug. It remains safe and effective and freely available for clinical use. This fine is in response to the legalities of marketing, not as a response to how it works or is manufactured.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
The aging neck is one of the most bothersome features of facial aging, whether it be a man or a woman. This is very evident as patients get older (greater than 55 or 60) and often is the sole focus regardless how the rest of the face is aging. For many men, the sagging neck is often their only facial aging concern.
Often a surprise to many patients is that the traditional facelift is the primary surgery to improve the sagging neck. While many perceive that a facelift is a total facial rejuvenation, they erroneously believe that the neck is treated differently with a ‘necklift’. Understanding that a facelift and a necklift is the same operation is a revelation for many.
For some older patients with severe neck sagging or a ‘turkey neck’, they simply do not want to go through a facelift. In most men in particular, the facelift concept and the lack of significant hair around their ears motivates them to pursue a different option. Rather than try and persuade patients to go through a procedure they don’t really want or can’t afford, I have used in my Indianapolis plastic surgery practice an uncommon option.
The direct neck lift is one limited form of facelift that just deals with the neck only. By cutting out the neck wattle directly, a dramatic change in one’s neck contour is achieved. It would be fair to say that the direct necklift produces a more dramatic neck profile change that is strongly resistant to future aging concerns caused by skin relaxation. Rather than shifting skin back in a traditional facelift, inches of skin and fat are permanently removed and platysmal muscles strongly tightened in the direct neck lift. It is simpler, faster, has next to no pain, and involves very little recovery of any significance.
But the beauty of the direct necklift is marred by one potential concern, which is why it is rarely done, that of neck scarring. That is the price that is to be paid for its simplicity and effectiveness. But how bad is this scarring? Is it slight or is it significant? Many who have never actually performed the procedure believe that the risk of poor scarring makes the direct necklift not a viable treatment option. That has not been my experience.
When speaking about necklift scarring, it is important to point out that the vast majority of patients I have treated are older men, age 65 or older. That is an important point for two reasons. The bearded skin of men allows for the most favorable s exposed scar location. Between the thickness of the skin, the healing potential of hair follicles and sweat and oil glands and the daily shaving (microdermabrasion scar treatment) that most men do, scars are set up to heal favorably. Secondly, this male population is very motivated as the other alternative (facelift) is even less appealing.
The scar pattern from a direct necklift is not a straight line. Vertical excision alone will leave redundant tissue under the chin above and along the thyroid cartilage below. Rather it is a vertical excision pattern that is combined with horizontal ellipses at either end, forming a ‘candlestick’ or ‘fishtail’ pattern. The very center of the closure in the middle of the neck will bear the zone of greatest tension. This is often relieved with a z-plasty to prevent central scar hypertrophy or widening. This is done in about half of the cases. Such an excision pattern has shown to produce remarkable neck changes in profile.
The scars from a direct necklift usually settle quite quickly and the typical early redness of scars fades by three months or so. While a very fine line vertical neck scar can be seen on very close inspection, it is largely inconspicuous in all men. The horizontal submental and low neck line scars become invisible. The redness of the scar persists longer in women and may be more visible which is why it is usually a gender-biased procedure.
While the potential scarring is an appropriate concern in the direct necklift, careful patient selection can make for a very satisfied patient. I have yet to formally revise any neck scars but have injected several raised scars of a cm or so in the tight central neck zone.
Dr. Barry Eppley
Indianapolis, Indiana
Case Study: Combined Vertical and Horizontal Chin Lengthening in Men
Author: barryeppley
Background: The chin is one of the facial prominences and the most noticeable part of the lower jaw. Horizontal chin shortness has been recognized for many decades and has largely been improved through the use of synthetic implants. Placing an implant on the front edge of the bone is a simple and relatively uncomplicated method of horizontal increase.
Great results can be seen in many profile examples of chin implant augmentation but the chin and the face is more than just a side view. Patients see themselves more commonly in the front view and this perspective is becoming appreciated in chin surgery. The other dimensions of vertical length and transverse width have greater impact in the frontal view and also have an impact on chin appearance. Since a strong chin is a well recognized male facial characteristic, the chin should be enhanced from three-dimensional changes.
Case: This is a 28 year-old male who previously had an implant placed for a short chin. While there was an improvement, he was still not happy with the final appearance. He had an implant that provided 8mms of horizontal advancement. In assessing his chin with computer imaging, his chin was slightly short horizontally by 3mm to 4mms but was also vertically deficient by 5mm to 6mms. He also thought his chin was wide as well.
Given the needed changes to achieve a more pleasing three-dimensional change, it was decided that it could not be predictably done by a bigger implant. An implant could not provide enough vertical length improvement. An osteotomy was planned to not only make these desired changes but to replace what the existing implant has already created.
An intraoral approach was used to both remove the existing implant as well as perform the osteotomy. The existing pocket of the implant had already made most of the dissection needed for the osteotomy cuts. The capsule of the implant pocket was removed, exposing the raw bone surfaces. With a reciprocating saw an angled horizontal cut was made below the mental nerves. The chin segment was downfractured and then moved forward 11mms and opened up vertically 5mms. The backledge of the chin segment was put to the bone of the upper chin bone as a point of rotation for the vertical opening. It was secured using a custom-bent chin osteotomy plate. The chin implant was cut down in size and used as a fill for the step of the chin osteotomy. This was done to prevent further deepening of the labiomental crease.
Chin osteotomies create more swelling after surgery than implants. It usually takes about ten days after surgery until the chin returns to a more normal appearance and three weeks for most of the swelling to go away. While many patients can expect some temporary lower lip numbness, he experienced very little. The improvement in the side view shows the desired moderate horizontal advancement.
In the front view, however, the increase in vertical length is more apparent and gives the chin better facial balance. While it is often stated that the lower face should be 1/3 of vertical facial height, in men the lower facial height should be slightly greater than 1/3 of total facial height.
Case Highlights:
1) Changing the shape of the chin is more than just about horizontal advancement. Vertical length and width of the chin must also be considered for the best aesthetic result.
2) Mild vertical lengthening of the chin can be done with an implant that is secured on the inferior edge of the bony chin.
3) When more than a few millimeters of chin lengthening is needed, an opening osteotomy is best. It can be done to only lengthen the chin or bring it forward as well as with a vertical increase.
4) When a chin implant has failed to achieve the desired aesthetic outcome, a chin osteotomy can be considered which offers greater options for some chin changes.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
Background: The nipple, technically known as the nipple-areolar complex, is present in both men and women. While it has a functional role in women, it is a non-functional vestigial structur in men. While a man’s chest would look strange without it, it aesthetically should blend in and be relatively non-prominent. Changes in the size and shape of the nipple are undesireable.
One of the undesireable topographies of the nipple is when the nipple is too long or enlarged. Rather than having a fairly smooth chest contour across the nipple’s surface, a prominent nipple creates an obvious two-tiered structure. This not only sticks out and is obvious when one is bare-chested but protrudes through shirts. ‘High beams’ in men is particularly bothersome to most men and is a source of embarrassment. Concerns about a prominent nipple can affect what type of clothes to wear.
Case: This is a 24 year-old male who was concerned about his prominent nipples. He said they were not always so and had appeared just a few years ago. They stuck out all the time and he was not comfortable wearing any type of form fitting shirt. Exposure to cold made them stick out even further.
In discussion about their reduction, he was not concerned about whether any feeling remained in them. He was most concerned that they were as flat as possible and did not have any noticeable scarring. Two techniques for nipple reduction were reviewed, wedge excision and circular or donut reduction. Wedge excision nipple reduction is essentially an amputation method where it is completely removed. It will make the nipple completely flat (because it is gone) but there will be no tiny mound or slight raised area where the nipple would normally be. The invisible scar will have the same tissue characteristics and scar as the surrounding areola. The circular method removes a ring of nipple tissue at its base and shortens it. This will not make it flat and will leave a smaller raised nipple mound. Feeling in the nipple may be maintained after.
Under local anesthesia in the office, the nipples were removed by wedge excision that were vertically oriented. The excised area was closed with small dissolveable sutures. The only dressings applied were glued on tapes that only covered the diameter of the areolas. The entire procedure was completed in 30 minutes.
The results are immediate without swelling or bruising. There are no restrictions from any activity after surgery. One can shower, swim and workout the very next day. The results will be permanent as the nipple can never grow back.
For those men, young or old, that are bothered by a long or prominent nipple can quickly solve this problem without pain, recovery, or prominent scarring.
Case Highlights:
1) Nipple protrusion in the male is a source of embarrassment and usually develops after puberty in most cases.
2) The wedge excision (amputation) technique of nipple reduction is usually preferred as it assures that the nipple will be completely flat.
3) Nipple reduction surgery is a simple office procedure done under local anesthesia. There is no recovery or physical restrictions after the procedure.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
Injectable fillers are a tremendously popular method for immediate enhancement of the lips and cheek-lip grooves. They have revolutionized cosmetic improvements of thin lips, lip lines, and a deepening nasolabial groove. With over a dozen injectable fillers to choose from, patients have a variety of options in both the cost of treatment and how long the effects will last.
One choice patients don’t have, however, is that the treatment requires a needle to create its effect. Despite it being a very small needle for most types of fillers, it is not a pain-free experience. Patients may enjoy the benefits but they have to endure the injection session to get it. The manufacturers of these materials is well aware of this concern and many now incorporate a local anesthetic in the injectable filler. While this provide some numbing effect, the needle must first pierce the skin to inject the filler-local anesthetic combo.
Therefore, a need still remains to get past the discomfort of the needle passing through the skin. While many use ice and other topical strategies, they are not that effective. One highly effective method, but one that uses a needle as well, is that of intraoral or dental nerve block techniques. On the surface, the use of one needle to defer the pain from another seems contradictory. However, skillfully placed intraoral injection can be made near painless with the right technique. The problem is that most practitioners have never been trained or are unaware of these time-tested facial local anesthetic techniques.
The first step in this technique is to use only a 1cc syringe and a long 30 gauge needle. Use a 2% lidocaine solution for the injection. While the use of epinephrine in the lidocaine may not seem needed for any lasting effect, it seems to create more profound skin anesthesia. For the cheek-lip groove, two injections placed just under the maxillary vestibule of 0.5cc each using the canines as vertical guides can really make these injections painless. If you shake and squeeze the lip while giving these injections (an old but effective dental maneuver), they can barely be felt.
An alternative to these maxillary vestibular injections is to inject the cheek-lip groove right under the skin. These are quick and not as uncomfortable as injecting a viscous filler material under pressure. The easy flow of the liquid anesthetic through a 1” long 30 gauge needle makes the injection minimally uncomfortable. But the anesthesia is profound and prepares the area well for the greater distension from the various filler materials.
For making the upper lip numb, these same two injections are used. But these alone will not block the entire upper lip. The central third, or the tissue between the philtrums, will be missed by these injections. It requires a small injection (.25cc) just above the upper lip frenum. This is a very tender area but is less painless than injecting a completely sensate middle third of the upper lip.
For the lower lip, injecting the vestibule just below the canines can effectively block most but not all of the lower lip. Again the central third is often missed and the vestibule below it may need a supplementary injection.
Having as comfortable as possible injectable filler treatment session is important given their temporary nature. If your injector is not taking the time or putting forth this effort to make you comfortable, it may be time find someone else who will.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
Background: Facial beauty is well known to be highly influenced by proportions and symmetry. Dividing the face into thirds, in either frontal or side views, is an established method of determining vertical facial balance. While this beauty concept is well acknowledged, putting it into practical use is difficult. Few facial structures can be easily changed vertically unlike increases in projection (horizontal) or transverse width.
The only facial structure that can easily be changed in the vertical dimension is the lower third of the face, that of the mandible. Such vertical mandibular lengthening is most commonly done through orthognathic surgery by mandibular advancement, either alone or in conjunction with maxillary downgrafting. But onlay augmentation can also be done along the inferior border of the mandible. (jawline It is not commonly done or thought of as there are no stock implants available that make it easy to do.
Case: This is a 21 year-old female who was concerned about her jawline, specifically that it was not long enough. She wanted a longer and more pronounced jawline. Her face was overall wide in all thirds including the jaw angles. She had wide-set eyes (type 1 hypertelorism) that were quite prominent with a lot of scleral show. But her lower face was vertically short with a small mouth horizontally. She had adequate horizontal chin projection but was short between the lips and the pogonion chin point.
A decision was between working with existing stock mandibular/chin implants or having a custom mandibular inferior border implant. Due to cost considerations ( doubling the cost of surgery), it was elected to proceed with off-the-shelf implants. One of the problems with this approach is that there is not a true mandibular border (jawline) implant. However, the geniomandibular implant composed of Medpor closely parallels this concept as it does lengthen the inferior border of the mandible (by 4mms) back to the mid-body of the mandible in most patients. By placing a spacer between the inferior border groove of the implant and allowing it to go back further and provide a taper, a modified jawline implant can be made out of a stock implant. This approach works if the implant is not needed to extend all the way back to the mandibular angle. Such a design is probably better for a female than a male who may need angle lowering as well. When combined with a mandibular angle implant, total jawline elongation can be obtained.
During surgery, a 3mm strip of Gore-Tex was added along the inside of the implant to get additional vertical length as well as extend how far back the implant would go. Through a submental incision, the implant was inserted and secured at the chin area with titanium screws. This implant can be placed without any risk of injury to the mental nerve as dissection is done below the exit of the nerve from the bone.
When seen at one week after surgery, the submengtal tapes were removed. She had minimal bruising and remarkably less swelling than one would anticipate. She has no restrictions on eating or jaw movement after surgery. While there was pain, it was less than what she thought would be. The implant can be seen to add to her vertical facial height without being excessively long.
Case Highlights:
1) Facial balance is a three-dimensional concept. The vertical dimension of the face, unlike horizontal projection and transverse width, is the least able to be changed and the most difficult historically.
2) Vertical elongation of the face for aesthetic balance can only be practically be done by changing the length of the mandible.
3) Aesthetic elongation of the mandible is done by onlay implant augmentation along the inferior border. This can be done using modified stock implants or having a custom implant made off of mandible model fabricated from a patient’s 3-D CT scan.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
There are numerous ethnic noses (Asian and African-American) that are characterized by having a low and wide nasal bridge. Such low nasal bridges are almost always associated with a tip of the nose that has poor definition and is wider and flatter. Rhinoplasty in this nose type requires the bridge and dorsal line to be built up higher. The choice in nasal augmentation is always between that of synthetic materials and one’s own bone or cartilage.
While I always prefer and use rib cartilage for significant nasal augmentation, some patients understandably do not want to have that done. This is particularly true in the patient who walks in for a cosmetic rhinoplasty without any prior nasal surgery. As a result, the use of synthetic implants, particularly composed of silicone, is the most commonly used nasal augmentation material around the world.
Synthetic nasal implants do have, however, a recognized history of problems such as infection, mobility, and even extrusion. This has led to the belief that all synthetic materials should be avoided in the nose. The extremely large experience in Asia with synthetic rhinoplasty, however, would indicate that this is not completely accurate.
Greater success in nasal dorsal augmentation with an implant is to place it, not just under the skin, but under the periosteum on the nasal bones. Elevating this periosteum can be difficult but is important particularly when the implant needs to be placed high on the nasal bones, which is usually needed in men. The significance of subperiosteal placement is that it will help prevent implant mobility and hide the edges of the implant better.
When it comes to nasal implants, what are our options today? The choices come to down material types (silicone vs Medpor primarily) and either a dorsal implant or an extended dorsocolumellar implant style. There are advocates for both material compositions and neither one is necessarily superior over the other. My preference is currently for a silicone-based material because of one factor…its ease of revision. Medpor gets a lot of tissue ingrowth which is biologically favorable. However, should it be necessary to revise it, it is a bear to get out. This translates into a fair amount of tissue disruption to remove it. Since the long-term potential for revisional rhinoplasty surgery is not rare with implants, I lean towards what would be easiest and least destructive to remove.
From a nasal style standpoint, I have concerns with an L-strut shaped implant. This implant comes down along the entire bridge of the nose, over or through the tip , and down to the base of the columella. (after turning 90 degrees at the tip) While it helps give the tip of the nose definition, it does so by putting point pressure in a fairly small area. This may make the nose tip too pointy and unnatural looking. (even a thin nose tip is round and not naturally pointy) With such pressure on the tip of the nose over time, it can become thin, get red, and ultimately develop extrusion. I have seen this more than once. The other problem with an L-strut is the potential for it becoming twisted and making the nose crooked. This can occur from simple scar contracture over time or from even slight trauma to the nose.
For these reasons, it makes more sense to me to keep an implant relegated to a dorsal style only. This places pressure over a much broader area of skin, lessening the risk of long-term tissue thinning problems. (provided it is not oversized) Once can usually find enough natural cartilage for tip and columellar grafting and support. It is the long dorsum where the implant provides its primary benefit of enough volume without a graft harvest Mobility and visibility problems can be improved with subperiosteal placement over the nasal bones as previously discussed. Modern dorsal nasal implants use a ‘saddle’ over the dorsal area for better fixation.
Some ethnic rhinoplasties need substantial dorsal augmentation as a foundation for its aesthetic success. When rib harvesting is not an option, a properly sized and placed nasal implant can have good long-term results.
Dr. Barry Eppley
Indianapolis, Indiana
Understanding the Differences Between a Cosmetic Abdominoplasty and a Medically Necessary Abdominal Panniculectomy
Author: barryeppleyAbdominoplasty, or a “tummy tuck,” is a well known procedure in plastic surgery that tightens loose rectus muscles and removes excess abdominal skin and fat. This recontouring of the abdominal wall area is exclusively done for cosmetic purposes to create a more flat and firm abdomen.
A panniculectomy, a cousin to the abdominoplasty, is different in that it involves exclusively the removal of a large and/or long overhanging apron of skin and fat in the lower abdominal area. While the pannus produces a stretching of the tissues from the anterior abdominal wall, such effects are not treated by any form of muscle plication as in a tummy tuck. The abdominal pannus occurs exclusively in morbidly obese individuals or following substantial weight loss, most commonly bariatric surgery. For the sake of classification, although this doesn’t change how it is treated, abdominal pannuses are graded by the American Society of Plastic Surgeons as follows:
Grade 1: pannus covers hairline and mons pubis but not the genitals
Grade 2: pannus covers genitals and upper thigh crease
Grade 3: pannus covers upper thigh
Grade 4: pannus covers mid-thigh
Grade 5: pannus covers knees and below
Unlike an abdominoplasty, a panniculectomy is performed for functional or medical reasons. As a result, it is often covered by insurance. There is little question that Grade 3 through 5 pannuses are almost always covered. Debate frequently ensues from the insurance company in the medical merits of removing Grade 1 and 2 types. This is where documentation of its medical problems is really important. Without adequate written evidence of symptoms, these lower grade abdominal panniculectomies will be viewed as a cosmetic procedure.There is little question that a massive overhanging apron of fat and skin creates chronic and unremitting skin problems underneath it. In addition to the need for enhanced personal hygiene (which is very difficult), treatment of these skin conditions may require antifungal creams and powders and occasionally antibiotics.
Not infrequently, there may be a need for a panniculectomy to be done with other abdominal and pelvic procedures such as hernia repair, hysterectomy, and even gastric bypass surgery. While it may seem obvious that getting rid of an obstructive pannus could only benefit the results of these surgeries, the insurance companies rarely see it this way. Citing that there is ‘insufficient scientific literature’ to support any benefit, these combined procedures are usually denied. How they can not easily see that such benefits as improved surgical access and less risks for wound healing problems after surgery is a mystery to me. Such concomitant coverage can be obtained if the documentation of skin problems is first obtained however.
Interestingly, an abdominal panniculectomy is not considered medically necessary when the main reason it is being performed is to relieve back, hip and knee pain. Even though the sheer weight of grade 4 and 5 pannuses clearly strain these areas, this consideration alone is insufficient for medical coverage. I have performed over the years numerous panniculectomies that were requested by an orthopedic surgeon to first be done before they would consider knee replacement surgery. Apparently, the musculoskeletal problems that it causes by orthopedic specialists is not sufficient evidence for medical coverage.
One procedure that is never needed and certainly not medically covered as part of a panniculectomy is liposuction. In fact, thinning out of an abdominal skin flap with liposuction can impact its blood supply and create wound healing problems. The wound edges in closing a panniculectomy are already compromised from chronic swelling and lymphedema in many cases. Adding liposuction to it may be ill-advised.
Dr. Barry Eppley
http://www.eppleyplasticsugery.com
Indianapolis, Indiana
Sitting a close second behind that of one’s eyes, the smile is the face’s greatest expression of emotion. The movement of the upper lip in a smile exposes the underlying teeth which plays a role in how attractive that smile appears. While the teeth are exposed in a smile, the gum tissue usually is not. When more than a little gum tissue appears between the upper lip and the teeth, it becomes known as the gummy smile.
The gummy smile is historically defined as more than 2mms of gum (gingival) show during a smile. The amount of gum show is a function of several factors including the height of one’s incisor teeth, the vertical length of the upper jaw and how much the upper lip moves up during smiling. As a result, there are different types of gummy smiles. Exceeding large gummy smiles (greater than 6 to 8mms of gum show) are primarily a bone-based problem. (length of the maxillary bone) Smaller amounts (2 to 4mms) are often more soft-based. (lip thickness and movement)
Treatments for the gummy smile are far from established or standard. Even though very large gummy smiles are best treated by a maxillary impaction (LeFort 1 osteotomy), that option requires a commitment of a course of orthodontics and a significant surgical procedure. In gummy smiles less than 6mms, most patients will be resistant to such a ‘drastic’ approach.
Soft tissue management of the gummy smile has been based on two goals; to diminish how far the upper lip moves (muscle weakening and/or release) and techniques to bring the upper lip down. (lengthen vertically) The combination of both approaches is really needed to make a significant difference in the appearance of the gummy smile. Neither approach alone has been shown to be effective long-term.
One of the primary upper lip elevators is the levator labii superioris. From its origin below the lower rim of the eye socket to its insertion into the underside of the skin of the upper lip, this vertical strip of muscle runs just outside of the nostril. Severing this muscle can be done from an incision inside the nostril and does weaken upper lip excursion. (as has been shown by Botox injections) But keeping the muscle ends from healing and returning to normal excursion requires something else. This is where the role of the spacer has been shown to be effective. Using a premaxillary implant after muscle release can help the muscle ends from healing back together again. At the least, this spacer helps push the upper lip down. While advocates for this spacer in the past have used synthetic materials, I prefer the use of rolled allogeneic dermis. It is soft, can not be felt like an implant, and will integrate naturally into the surrounding tissues. This is a better way to introduce scar between the muscle ends without risk of long-term complications.
The other component of soft tissue management is upper lip release and lengthening. The upper lip can be released from the inside and its attachments freed up from the bone along the pyriform aperture to the canine fossa. By making the initial incision vertically through release of the maxillary frenum, such released upper lip tissue can be put back together in a classic V-Y closure pattern which will provide some upper lip length from the inside. When combined with a levator myotomy and spacer, realistic gains in upper lip length and decrease in gingival show can be anywhere from 2 to 6mms.
Such soft tissue gummy smile reconstruction can be done as an outpatient procedure under IV sedation in a simple one hour procedure. While it could also be performed under local anesthesia, patient comfort is better under some a little sedation. There will be some considerable swelling of the upper lip which returns to normal in about 10 days. The upper lip will move a little unnaturally for a few weeks after surgery. While the amount of gummy smile reduction will vary per patient, there are no long-term risks or deformity than can occur from this approach.
Dr. Barry Eppley
Indianapolis, Indiana
Injectable Sternoplasty (Pectus Excavatum Repair) - Kryptonite Bone Cement as a Sternal Augmentation Material
Author: barryeppley
Pectus excavatum, also known as funnel chest, is a defect characterized by differing levels of sternal depression. The deepest area of the sternal depression is always on the lower third of the sternum near the upper abdominal area. The lower costal or rib cartilages dip backward to increase the deformity or depression and push the sternum posterior backward towards the spine.
Significant pectus deformities are treated when the patient is young, usually between 12 to 18 years of age. At this age, the plasticity of the cartilages make this age group the ideal period for repair. While extensive cartilage resection (Ravtich approach) has been the historic approach. This radical operation has been replaced by the Nuss Procedure which involves the placement of a large curved bar through incisions on the chest wall. The bar is rotated into position and kept in place for 2 to 3 years.
But not all sternal reconstructive surgery leaves a perfectly flat or well curved sternum. In addition, some patients have very small sternal depressions that were either not recognized for early treatment or were not significant enough for any form of sternal reshaping and respositioning. Such cosmetic sternal deformities have been traditionally treated with onlay implants usually composed of preformed or custom carved silicone. Gore-tex blocks and sheets have also been used as sternal inserts.
But these synthetic materials have not been without their complications including infection, seroma formation, and capsular contracture. This has resulted in either their need for removal or the outcome of a hard and unnatural feeling implant. This is largely because these synthetic materials are not intended to be bone substitutes or replacements so they never integrate and become an extension of the natural sternal bone. Better sternal onlay materials would be an asset and could provide a better option for smaller sternal depressions that don’t warrant invasive bone reshaping.
The ideal sternal onlay augmentation material would adhere to the bone surface, have bone-like firmness and fracture resistance, and be injectable. The need to be delivered into the sternal site by injection is critical as any incision across the sternum is a cosmetic deformity by itself. Of all available bone substitute materials historically used, none fulfill all of these criteria. Most are hydroxyapatite-based which are neither injectable or fracture-resistant.
The recent commercial introduction of Kryptonite bone cement has the potential to fulfill these sternal criteria. Kryptonite Bone Cement is a non-toxic, porous, adhesive bone substitute material that possesses bone-like mechanical properties. It is composed of naturally occurring fatty acids and calcium carbonate. It’s three ingredients are mixed together at the time of surgery to create an initial liquid material that converts into a firm putty within minutes. It is Kryptonite’s liquid phase after mixing that makes it injectable.
Kryptonite bone cement has been shown experimentally to be an easily injectable material for limited incision or minimal access cranioplasty. It can flow through small diameter (3mms) plastic tubing, can be easily molded through the skin by outward digital molding pressure, adheres to the bony pocket created, and does not stick to the overlying skin. Its success for a cranial surface suggests that it would work equally well on the sternum, which represents just another flat bone surface. Through a small (< 10mm) lower sternal incision, a subperiosteal pocket can be easily created and injected. The material can be molded to fill a sternal defect and harden in 15 minutes. Once set, it will feel like natural bone and will encapsulate with the underlying sternum
Kryptonite bone cement represents a viable sternal augmentation material. Its ability to be placed by injection opens up treatment possibilities for those with sternal depression deformities that would not otherwise merit more extensive surgical reconstruction.
Indianapolis, Indiana