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Archive for the ‘OR snapshots’ Category

OR Snapshots – Sagittal Crest Skull Reduction

Sunday, August 13th, 2017

 

A bony ridge that runs down the midline of the head is known as a sagittal crest. This is a palpable raised ridge of bone that when high enough can cause a peak-shape to the head from the front view. The normal more convex shape off the head becomes more triangular shaped. This is most commonly an aesthetic concern in the male that either has very short hair or shaves their head.

Reduction of the sagittal crest skull deformity is done with a burring technique. Using a high speed handpiece and carbide burr, the bone is shaved down to a smooth contour. The bony ridge is thicker than normal skull bone so it can be safely reduced. But because this is an aesthetic deformity thoughtful consideration must be given to the incision needed to do the burring.

Working through a small scalp incision using a high speed handpiece safely requires protection of the surrounding hair and skin edges. This is best done by stapling gauze sponges along the edges of the scalp incision as well as placing a rubber guard over the length of the shaft of the burr. This prevents any risk of hair getting caught up in the rapidly rotating burr or its shaft. It is also important to only operate the handpiece when totally inside the subperiosteal tissue tunnel along the bony sagittal ridge.

Sagittal crest skull reduction can be done both effectively and safely through a fairly small scalp incision. This incision is usually placed perpendicular to the sagittal crest. In posterior sagittal crests the incision is placed on its most posterior end. But in long or more extensive sagittal crests the incision is placed at its midpoint to provide equal access to both ends of the bony deformity.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Custom Occipital Skull Implant

Saturday, August 12th, 2017

 

There are over fifteen types of aesthetic skull deformities. But the most common amongst them is various forms of flattening of the back of head. Perhaps because the back of head is exposed to various pressures in utero and after birth more than any other area of the head, it is prone to deformational pressures that can cause its shape to be flatter. This flatness can affect just one (plagiocephaly), both sides (brachycephaly) or even subtotal portions of either side.

The most effective treatment for flat back of the heads, regardless of its size, is a custom occipital skull implant. Made from the patient’s 3D CT scan, the implant design can be made to cover all flat areas and match any asymmetries between the right and left sides. The flexibility of a silicone implant allows the precisely-designed implant to be inserted through the smallest possible scalp incision usually placed at the mid-portion of the occipital scalp.

In surgery the flatness of the head can be fully appreciated. With the patient asleep in the prone position, wetting of the hair allows the back of the head shape to be completely seen. Laying the custom implant on it allows one to see how much the contour can be improved. Because it is not under the scalp its size looks smaller than the bone area that it will cover and shows more projection that will be actually achieved.

Recovery from skull implant surgery is fairly quick. One can expect some swelling and bruising in the temporal areas on the sides where the implant is primarily placed. This is to be expected due to the subperiosteal dissection needed to make the implant pocket. Since the dissection is done under general anesthesia in the prone position, combined with effects of gravity, such tissue fluids work their way towards the face. The facial swelling and bruising resolves by ten days after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Fate of the Cut Muscle Edge in Temporal Reduction

Sunday, August 6th, 2017

 

Temporal reduction is an effective method for narrowing the wide head. The wide head is defined as the area above the ears that has too much convexity or fullness. Extreme fullness at the sides of the head occurs when the width of the head gets near a vertical line drawn up superiorly from the inside of the superior helix of the ear. But many affected patients may feel they have too much convexity even when its width is well inside the profile of the ear.

While many feel that temporal bone reduction is the key to head width reduction, it actually is not. The thickness of the posterior temporal muscle is what constitutes a significant part of the side of the head. Its removal makes an immediate and visible reduction in its convexity, changing it to a completely or near complete flat profile. Surprisingly the removal of the posterior temporal muscle has no functional impairment on lower jaw motion or function.

In the technique of temporal reduction by myectomy, which is usually performed through a postauricular incision, a vertical cut through the temporal muscle is made from the attachment of the ear superiorly to the temporal line at the top of the skull. All muscle behind this line is removed leaving the overlying fascia in place. With muscle thicknesses averaging 7 to 9mms in thickness this leaves a very palpable and sometimes visible step-off in the temporal contour. The posterior cut edge of the large remaining anterior temporal muscle is cauterized for both hemostasis and in the belief that muscle atrophy will eventually smoothest the shape of the cut edge of the muscle.

I had the opportunity to validate what happens to the back edge of the cut temporalis muscle. Three years previously as part of awn overall skull reshaping procedure, the posterior temporal muscle was resected in a full-thickness vertical fashion from the bony temporal line inferiorly down to the ear. In a more recent skull reshaping procedure on the same patient, the temporal regions were inspected. It was observed that the original cut edge of the muscle does thin out and recontour with healing as suspected.

 

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Extended Arch Cheek Implants Replacement

Sunday, July 16th, 2017

 

Cheek implants can be the most difficult to decide preoperatively as to their style and size. Because the cheek is an oblique structure and not a profile one, it defies any exact measured target to achieve. The cheek does have very specific zones of augmentation, four to be exact, and it becomes important to consider these cheek zones when selecting the implant style that can achieve the patient’s desired midface look.

Most cheek implant styles focus on augmenting either the malar body and/or the submalar region underneath it. These are the central zones of the cheek. While effective for some patients, they are prone to creating a bulge or bump effect particularly if the size of the implant is too big. This is because the cheek, also known as the ZMC (zygomatico-maxillary) complex, is a bony structure that has three visible legs or extensions to it that emanate out from its main body. To look more natural many cheek implants should flow into these extensions more fully.

One newer cheek implant option is the malar-arch style. As the name implies it is a midface implant that augments the malar body but has a long posterior tail to it that goes back along the zygomatic arch. It extends back along the curved arch and stops before it reaches its temporal attachment. This provides a gentle sweeping augmentation across the cheek area and achieves a more complete and natural cheek enhancement. It is also the type of cheek look seen in many models, for example, whether that is their natural look or has been created by makeup or photo editing.

It has not uncommon that I see a ‘standard’ cheek implant patient who is dissatisfied with just augmentation of the malar-submalar cheek area. Exchanging these standard implants for an extended arch style usually provides a more desired midface enhancement effect. It is the creation of a more horizontal line across the side of the face that is often sought out today.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Facial Cyst Removal

Saturday, July 15th, 2017

 

Lumps and bumps of the face are common. They are usually located in the subcutaneous layer right beneath the skin and, in some types, are directly attached to the underside of the skin. The most common pathologies are sebaceous cyst, dermoid cyst and lipoma. While they are benign they will usually continue to grow. While initially felt as a small non-visible lump, they often create an external distortion as they grow.

Facial cysts are mostly a cosmetic concern provided they do not get infected. (dermoid cysts and sebaceous cysts can, lipomas will not) While they can be quite disconcerting when they are found and they often continue to grow slowly, they can be removed in most cases with minimal scarring if done properly. Unsightly scars can make the facial area look worse in appearance than the original pathology.

While placing the incision in a skin crease away from the facial lesion site has the advantages of a more hidden scar, this is not always possible to do. The commonly used method is with a small skin incision directly over the lump. This also has the advantage in dermoid cysts that the attached skin pore is also completely removed to avoid cyst recurrence. In most cases the incision will need to be almost as long as the mass to ensure that its walls and contents are completely removed. These can be done under local anesthesia in the office in teens and adults. Infants and children will require an anesthetic to perform it.

As long as the incision is placed parallel to the relaxed skin tension lines of the face, even though it is in an exposed area, the scarring will be quite acceptable. Skin closure of these facial lesions excisions is often done in a subcuticular technique so no sutures need to be removed and no suture track marks all be left behind.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Titanium Cranioplasty

Tuesday, July 4th, 2017

 

Reconstruction of the skull can be done using a variety of alloplastic materials. Over the years synthetic cranioplasties have evolved from solid metal plates to bone cements to computer-generated implant replacements of lost bone.  While some techniques are most historic than others, each still has a role to play in contemporary cranioplasty surgery.

When there js adequate time to have a 3D computer-generated implant reconstruction done, this is almost always the preferred method for large full-thickness skull defects. The strength of the materials (HTR, PEKK, PEEK) and their exacting fit makes them as ideal as possible for a non-autogenous reconstruction.

But when time does not permit the necessary fabrication time for a 3D implant, several alternatives exist. One option is that of bone cement. While there are several different types of bone cements, they will require a backing for their use in large full-thickness skull defects.  The hydroxyapatite bone cements, in particular, do not have enough strength when wet to resist displacement and potential fracture. Even with traditional PMMA bone cements, a rigid backing is still structurally beneficial

The best intraoperatively fashioned backing for full-thickness skull defects is titanium mesh. It comes in a variety of geometric configurations. But the hexagonal pattern allows for the most malleability of its shape and adaptation to the surrounding bone edges. It also has a lot of metallic  edges onto which bone cements can grab onto in the setting and curing process of the material.

While traditional metal cranioplasty refers to an outer solid cover over the defect, a mesh metal cranioplasty refers to its use as a backing for bone cement materials. If a mesh material is placed in the outer surface of the bone alone, tissue contraction around its mesh shape will eventually reveal these irregularities particularly in the exposed forehead area.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Removal Cartilaginous Ends

Monday, June 26th, 2017

 

Rib removal is the last surgical option for maximal waistline reduction. After liposuction the only remaining anatomic obstruction is the lower ribcage. The outer and downward flare of the free floating ribs does influence the width of the waistline at the horizontal level of the umbilicus. Contrary to its perception rib removal is not a myth or an urban legend but an actual procedure that is both safe and effective. The aesthetic tradeoff is the small fine line scar on the back which is needed to do the procedure.

Rib removal is really subtotal rib removal, only the outer portion of the rib is removed. There is no aesthetic benefit to removing the whole rib by disarticulating it from its vertebral facets. The rib only needs to be removed back to the outer edge of the erector spinae muscle. At this point a full-thickness bony cut is done to separate from its medial attachment.

The rib is then dissected out laterally in a circumferential suboperiosteal fashion until its cartilaginous tip is reached. At the cartilaginous end numerous muscular and fascial attachments exist. These are easily stripped off. Thus aesthetic rib removal involves only one bone cut per rib as the distal end is ‘free’. (not attached to bone but its does have soft tissue attachments.

In some cases of rib removal for maximum effectiveness, rib #10 is also removed in a subtotal manner also. Even though it is not a true free floating rib it still has a cartilaginous attachment to the anterior subcostal ribcage at the 7-8-9-10 cartilaginous unit.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Graft Tip Rhinoplasty

Thursday, June 22nd, 2017

 

While many rhinoplasties are reductive in their overall reshaping effect, some require the addition of support or structure through the use of autologous tissue grafts. Most noses can be satisfactorily augmented or rebuilt through the use of septal, ear or combining septal and ear cartilage grafts. But when such local and regional cartilages harvest sites are depleted or inadequate for the amount of augmentation needed, the rib is the remaining ‘go to’ cartilage donor site.

Rib grafts offer an unlimited supply of cartilage graft material when it comes to what is needed in the nose. Regardless of where it is harvested (inframammary or subcostal incisions), the amount of donor material is more than adequate. Issues such as curved cartilage shapes (ribs are rarely perfectly straight) and whether full-thickness or in situ harvesting methods are used may pose some graft limitations But these are overcome by experienced harvesting techniques.

In the tip of the nose, rib grafts are needed when considerable tip lengthening or derotation changes are needed.  (rib graft tip rhinoplasty) Placing an L-shaped cartilage construct at the end of the nose has a powerful tip augmentation effect which is only limited by the ability of the skin to stretch over it and still have adequate perfusion after surgery.

Rib grafting to the nasal tip is often an onlay technique where the grafts are placed over the existing medial footplates and dome cartilages. A pocket is made under the columellar skin below the incision down to the anterior nasal spine into which one carved piece of the tip graft is placed. (vertical graft component) A lower dorsal-dome cartilage graft (horizontal component) is fashioned and placed on top of the existing dome cartilages to be united at 90 degrees to the columellar piece. Suturing the two rib grafts together creates the new tip defining point.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Neurovascular Bundle Preservation in Rib Removal Surgery

Monday, June 12th, 2017

 

Rib removal can be done for a variety of aesthetic and medical purposes. The most common aesthetic reason is for horizontal waistline narrowing with the subtotal resection of the truly free floating ribs. (#s 11 and 12) Through a small obliquely oriented skin incision on the back the midportion of the ribs are identified just lateral to the erector spine muscle and cut. From that position the rib is then dissected out to its cartilaginous tip and removed.

One of the keys to rib dissection is that it is done in a subperiosteal plane. The periosteum is tightly wrapped in a circumferential manner around the bony rib. Getting under this tissue layer allows for the smoothest and cleanest plane of dissection but also preserves all surrounding structures. This is most relevant to the neurovascular bundle that sits in a groove on the inferior side of the rib. Elevating and preserving the artery and vein makes not only for less intraoperative bleeding but prevents inadvertent nerve injury/transection and the potential for chronic postoperative rib pain.

The subperiosteal rib plane of dissection is easiest on its superior aspect and harder to get out the neuromuscular bundle from its inferior bony groove. But the same instruments that are used to dissect the mucoperichondrium from the nasal septum are used to get the neuromuscular bundle out of its bony groove. Once started more proximal it is much easier to elevate out to the cartilaginous end of the rib. Once the rib is removed the vessels and nerve should be seen intact in the periosteal soft tissue cuff.

Rib removal is often associated with a destructive and very invasive surgery, undoubtably influenced by thoracic surgery  which has a different intent for its performance. From an aesthetic stand point it is important that rib removal be doing through small incisions and minimize any risk for chronic postoperative pain from intercostal nerve injuries.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Extended Temporal Implant

Sunday, June 11th, 2017

 

Temporal hollowing is commonly treated by injectable fillers and fat injections. While both of these injection methods have their merits, the assured permanent temporal augmentation method is with the use of an implant. Temporal implants are newer forms of facial implants that are specifically designed to replicate the soft feel of muscle rather than that of bone. It is the only facial implant that is designed to augment a soft tissue area.

Temporal hollowing is the result of fat atrophy, muscle wasting/thinning or a combination  of both. In modest to moderate amounts standard temporal implants do well in improving hollowing. They cover the lower half  of the temporal region from the zygomatic arch upward to the level of lateral brows.

In more severe forms of temporal hollowing the concavity extends up to the anterior temporal line at the side of the forehead. This encompasses the entire anterior temporal zone for which the standard implant is deficient in height. (vertical length) As a result an extended temporal implant has been designed that can augment the entire extent of temporal hollowing should it go all the way up to the forehead.

The extended temporal implant is placed through the same incision as the standard style. The length of the incision does not need to be extended to properly place it. Once the pocket is made the implant is inserted in a horizontal orientation and then turned 90 degrees for proper placement.

The extended temporal implant offers enhanced improvement for those so afflicted with more severe facial hollowing. Thin females, patients with medication-induced facial lipoatrophy, and extreme weight loss patients are the most common aesthetic indications for use of the extended temporal implant.

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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