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Archive for the ‘OR snapshots’ Category

OR Snapshots – Abdominal and Flank Liposuction

Sunday, February 26th, 2017

 

Liposuction is one of the most recognizable plastic surgery procedures and is the most commonly done body contouring operation. While there have been many innovations in liposuction devices and techniques over the past forty years since its U.S. introduction in the early 1980s, all such variations can produce effective fat reduction results when performed technically well.

Abdominal and Flank Liposuction one treated side only Dr Barry Eppley IndianapolisThe most common body area treated by liposuction remains the abdomen and waistline. Since this is a central depot area of excess fat accumulation it offers the most reliable and significant area for suctioned fat removal. Performed in the supine position, all of the abdomen and the flanks (love handles) can be treated. The technique of treating one full side first allows both an appreciation of the preoperative body contours but a reductive target for symmetry.

Larger Volume Body Liposuction aspirate Dr Barry Eppley IndianapolisThe safe amount of fat to remove in a single session of suction aspiration has been an issue of discussion. It is generally accepted that five (5) liters of liposuction aspirate is the maximum amount that can be removed without causing significant physiologic changes to the patient after surgery. While this is not an absolute number due to differences in patient’s body surface areas and weight, it provides guidance for what is an elective aesthetic operation. Such volumes of liposuction fat removal, however, is rarely an issue in abodminal and flank liposuction.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

Wednesday, February 8th, 2017

 

Cheekbone reduction surgery typically is done by a double osteotomy technique. The anterior cut allows the posterior body of the zygoma (main body of the cheekbone) to move in. The posterior cut is done at the back end of the attached zygomatic arch just in front of the ear. These two cuts allow the whole side of the cheekbone to move inward. This creates the facial narrowing effect.

The anterior cheekbone osteotomy is done from inside the mouth and various design patterns have been described for it. But regardless of the design of the bone cut, it needs to be secured with a plate and screws to prevent inferior migration and sagging cheek soft tissues. Failure to do so is the most common cause of postoperative loss of cheek volume.

Posterior Zygomatic Arch Osteotomy Cut Dr Barry Eppley IndianapolisConversely, the posterior cut through the back end of the zygomatic arch is done externally through a skin incision. By making an incision at the back end of the sideburn hair, direct access can be done right down to the temporal process of the zygomatic arch.  An angled bone cut is then made just before the arch joins the temporal bone. This bone cut, combined with the anterior bone cut, allows the whole cheekbone segment to move inward. With plate and screw fuxation of the anterior, such rigid fixation may not be needed on the posterior cut to hold it in. The angled cut allows the tail of the arch to move inward and being self-locking.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – 3D Forehead Reconstruction Implant

Tuesday, February 7th, 2017

 

Forehead reconstruction encompasses a variety of inlay and onlay bone procedures. Reconstruction of full-thickness frontal bone defects most commonly occurs from either neurosurgical procedures where a craniotomy bone flap has been lost or from skull bone loss due to trauma. While replacing the lost bone can be done by using the patient’s own bone, this is very much like ‘robbing Peter to pay Paul’. A large segment of full-thickness skull bone must be taken from another location on the skull, split into two halfs and then both skull defect sites have to be reconstructed with the bone segments.

As a result, the most common method for full-thickness skull bone loss is a synthetic material. There are a variety of implant materials available for use, but the use of 3D imaging and computer design dominates how such forehead bone reconstructions are done today. The precision fit of a 3D implant design made of a strong implant material is appealing for both surgeon and patient alike.

Custom Forehead Skull Implant Reconstruction Dr Barry Eppley Indianapolis3D forehead reconstructive implants can be made of metallic titanium, HTR polymer, PEEK and PEKK materials. Using a 3D CT scan the implant is prefabricated and usually fits with little modification needed. (often no adjustments of the perimeter of the implant are needed) This is an example of a 3D  forehead reconstruction implant made from PEKK material to replace a lost frontal bone flap due to infection from a prior intracranial tumor resection procedure.

PEKK is a synthetic polymer composed of polyetherketone ketone material. It is firm implant material that has a a high resistance to fracture. In addition it has a lighter weight than other materials like titanium. Its lightweight, high impact resistance and being able to be laser sintered in fabrication make its an excellent 3D cranial implant.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Buccal Lipectomy Zone

Wednesday, January 25th, 2017

 

The buccal fat pad is the only completely encapsulated fat collection in the face. Besides its capsule it is a unique piece of fat anatomy as it is a distinct pad that has a well identified vascular pedicle providing its main blood supply. Because it is an easily found and removed piece of facial anatomy with little consequence in doing so, it is a common aesthetic procedure. Removal of the main body of the buccal fat pad (buccal lipectomy) can a visible external facial change by reducing the fullness of the cheeks which can create better cheekbone highlights.

Buccal Lipectomy Dr Barry Eppley IndianapolisBut in facial derounding procedures the buccal lipectomy procedure is often misunderstood for where it creates it facial effects. Of the three aesthetic cheek zones influenced by fat (buccal, perioral mound and medial cheek), removal of buccal fad creates its effect just under the cheekbones. It does not go lower down to the mouth level and does not extend closer to the nose. Those are different fat zones which can also be treated. (perioral mound liposuction, medial cheek liposuction)

The best way to know what effect a buccal lipectomy will have on the face is by drawing specific horizontal and vertical lines. If a vertical line is drawn from the corner of the eye down the mouth corner and a horizontal line is drawn from the tragus of the ear to the mouth corner, the northwests section above the intersection of the lines is the buccal zone. This is where the fullness of the face will be reduced by a buccal lipectomy.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Perioral Mound Liposuction

Sunday, January 22nd, 2017

 

There are numerous fat compartments on the face that can be surgically reduced. The most recognized and easily removed is the buccal fat pads. (aka buccal lipectomy) Located just under the cheekbones, it is a very discrete collection of fat that has its own pedicled blood supply and a surrounding capsule. It is removed from an intraoral approach through a small incision just opposite the molar teeth.

While the buccal fat is a large collection of fat compared to the rest of the face, it is frequently given more credit that it is due. Its removal affects the fullness of convexity of the cheek just under the cheekbones. It does not extend very low onto the face and its thinning effect will be relegated to the upper cheek area. If you drew a line from the tragus of the ear to the corner of the mouth, a buccal lipectomy has its effect above this line.

Perioral Mound Liposuction markings Dr Barry Eppley IndianapolisBelow this drawn line sits another smaller collection of facial fat known as the perioral fat or, when bulging, the perioral mounds. This is a subcutaneous non-encapsulated fat collection that sits between the skin and the buccinator muscle. It is located at the southern end of the cheeks or its lower half. It has no anatomic connection to the buccal fat pad. In rare cases the buccal fat pad has been known to fall or prolapse into the perioral mound area.

Removal of perioral mound fat is done by very small liposuction cannulas. It is never an impressive amount of fat that is removed but a little fat reduction does make for a visible external effect. It is a good companion to buccal lipectomies for a more complete cheek reduction effect.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Two-Piece Custom Skull Implant

Saturday, January 21st, 2017

 

Skull reshaping using implants is the only effective method for augmenting head shape. While certain bone and muscle removals can be done for more limited skull reductions, skull augmentations can produce much more dramatic changes. In essence, the stretch of the scalp is far more permissive than the thickness of the skull bones.

In very large skull augmentations the scalp can become a limiting factor and may require a first-stage scalp expansion. But beyond the ability of the scalp to accommodate a large skull implant, getting the proper shape and dimensions of the implanted material is the other major challenge. This is overcome today using a custom design approach with a 3D CT scan. Custom skull implants can now be made to cover any area of the skull including the entire bony skull if desired. (forehead back to occiput)

Two Piece Custom Skull Implant Dr Barry Eppley IndianapolisManufacturing very large or total custom skull implants is difficult because they can cover more than a 180 degree arc with thin edges. To avoid manufacturing problems, a two-piece approach to the implant’s fabrication and insertion can be done. Creating two interlocking edges allows for a two-piece custom skull implant to be accurately reassembled on the patient’s skull the way it was designed.

Very large skull implants are most accurately placed using a long scalp incision. This patient shown here already had a full coronal incision so its total length was used. If such a long scar was not already present, a shorter incisional length could be used.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Macroporous Custom Skull Implant

Wednesday, January 11th, 2017

 

Custom skull implants have become a reliable and safe method of various types of skull augmentation. Made from the patient’s 3D CT scan, they cover the desired skull surface with a precise fit and a smooth outer surface that blends well into the surrounding bone/muscle areas. The most careful judgment has to be made in the thickness of its design so a competent and not overly tight scalp closure is obtained.

An obvious but often overlooked feature of most custom skull implants is that they are ‘large’. They can cover a significant surface area of the bony skull. This places an implant between the thick overlying scalp and the bone. While I have never seen this to cause any problems, it would be desirous to have some increased fibrovascular connections between the scalp and the bone. Since a silicone skull implant is not naturally porous this is not a biologic property such an implant would naturally have.

custom-skull-implant-ready-for-placement-dr-barry-eppley-indianapolisTo help achieve some integration of skull implants with the surrounding tissues, the concept of perfusion holes is used. This is were many 3mm to 4mm circular holes are placed through the implant. They can be thought of as ‘perfusion holes’. They will permit a very rapid tissue ingrowth through them, reconnecting the scalp and the bone with these tissue connections. They also serve to take one large implant pocket and make it many small pockets through this natural tissue quilting effect.

While these perfusion holes also help to fix the implant more securely into place, it does not make it any more difficult to remove or modify it later should the need arise. The tissue bands can be broken fairly easily in that process.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Open Rhinoplasty

Sunday, January 8th, 2017

 

Rhinoplasty surgery requires incisional access to perform osteocartilaginous reshaping. The most common historic technique was the ‘closed approach’ where all incisions were placed inside the nose. Because this provided limited visual access it took a lot of experience to master aesthetic nasal surgery. This was the standard in rhinoplasty until the 1990s were it was surpassed in usage by the ‘open approach’.

open-rhinoplasty-indianapolis-dr-barry-eppleyThe open approach degloves the skin off the tip of the nose and permits complete visual access to the entire underlying nasal structures. What makes it possible to expose the nose is the mid-columellar incision. This extra 6mms of skin incisional length connects with intranasal mucosal incisions to allow the nasal tip skin to be lifted off of the lower alar cartilages. While once controverial, the open rhinoplasty has become the standard technique in rhinoplasty today as it produces consistent and more reliable surgical outcomes.

Patients are often understandably concerned about a visible nasal scar with the open nasal approach. But the columellar skin heals so well that such a scar is virtually invisible in most patients. It rarely causes a scar problem and I have never seen a hypertrophic or keloid columellar scar. The only occasional columellar scar problem seen is a stepoff or notch along one of its sides due to less than perfect closure or premature incisional separation.

Interestingly, the widespread use of the open approach has led to a re-emergence of the closed approach. Now known as the ‘scarless’ rhinoplasty, the use of the closed approach is refinding a role in certain types of nasal reshaping surgeries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Abdominal Panniculectomy (Apron Removal)

Tuesday, January 3rd, 2017

 

The abdominal panniculectomy procedure is well known to be a ‘big’ operation. It is the supersized version of the traditional tummy tuck and is often judged by the weight of the pannus removed. The largest abdominal pannus I have ever removed is 85lbs and that was back in the pre-bariatric surgery era…when the abdominal panniculecomy was the only form of bariatric or weight loss surgery.

abdominal-panniculectomy-surgery-dr-barry-eppley-indianapolisOne of the challenges in this operation is to manage the considerable soft tissue mass, removing the most abdominal tissue that one can while still being able to close the wound without creating after surgery healing problems. When removed the abdominal pannus looks even bigger than when it is attached and hanging on the patient. The term ‘pannus’ is often associated with the word ‘apron’. It is easy to see why it might have that name as seen in this intraoperative picture where it could be worn like an apron once removed.

Beyond the light-hearted clothing analogy, the abdominal panniculectomy produces a dramatic improvement for the patient in many ways. It eliminates chronic skin infections and sores that develop underneath it and removes stressful weight from the back and knees that have to support and carry it around. It also allows the patient better clothing options, often allowing them to find outfits that fit better.

The abdominal panniculectomy is often thought of as a tummy tuck…and it is. But it is an operation that is much bigger in magnitude than most traditional tummy tucks as can be seen by the type of patient on which it is performed. White it is associated with a relatively significant rate of complications, like fluid collections and wound healing issues, these are often self-resolving issues and do not ultimately detract from the huge benefit that patients receive as a result from undergoing the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Injectable Diced Cartilage Grafting Technique

Monday, January 2nd, 2017

 

Rib grafts are a well known autologous graft in rhinoplasty for significant augmentation. The rib graft can be used as either a solid piece (en bloc) or can be diced into very small cubes and turned into a sausage-like wrap. Both rib graft methods have their advantages but the diced technique effectively eliminates any chance of graft warping, the most common aesthetic complication of onlay rib grafting in the nose.

diced-cartilage-graft-rhinoplasty-preparation-dr-barry-eppley-indianapolisBut the wrap containment method is not the only way to use a rib graft. For smaller dorsal defects diced rib cartilage can be placed through an injection method. If one has enough septal cartilage this can also be used similarly. In this method the diced cartilage is loaded into a 1cc syringe with an open barrel. (this has to be cut that way) This creates a loaded injectable cartilage graft syringe.

The key to using this cartilage grafting method is that it has to be placed through a narrow tunnel to the dorsal defect site. The tunnel serves as the containment method. Once inside the tunnel the graft is injected on withdrawal. It can then be molded into shape although the tunnel itself has already made most of the graft shape. The shape is held by the application of external tapes/splint.

It is easy to see that this is a linear grafting method that works by the alignment of the syringe for graft placement. This makes it best used for dorsal line defects from the radix down to the tip.

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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