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Archive for the ‘OR snapshots’ Category

OR Snapshots – Greater Occipital Nerve Decompression

Thursday, May 18th, 2017

 

Migraine surgery has become popular for the few select headache patients who fulfill specific selection criteria. Having reproducible headache symptoms that correlate to specific cranial nerve locations makes the concept of nerve decompression potentially successful. Based on the premise the nerve is being pinched as the initiator of the headache attacks serves as the biologic basis for the surgery.

One of the most nerve sites treated in migraine surgery is that of the greater occipital nerve. Known to be a major contributing factor in occipital neuralgia (cervicogenic headaches), it is a spinal nerve from the 2nd cervical spinal nerve. It emerges from between the first and second cervical vertebrae up through the deep neck musculature through the trapezius muscle and fascia to innervate the skin of the back and top of the scalp. It can become entrapped as it passes through the muscle and fascia.

Greater occipital nerve decompression is done through a midline incision at the low end of the occipital hairline. Dissection is done through the thick layer of subcutaneous fat down to the trapezius fascia. The fascia is opened in the midline and the nerve is dissected out from the underlying muscles. Once identified the nerve is traced deep and all surrounding muscle released. It is similarly traced up toward the scalp again removing muscle as well as a fascial release along the nuchal ridge.

The greater occipital nerve is a big nerve whose course through the muscle and fascia gives it plenty of opportunity to be compressed or squeezed by the surrounding tissues. Its surgical decompression is associated with no adverse sequalae other than how effective it is in creating symptom relief. In my migraine surgery experience the vast majority of carefully selected occipital neuralgia patients get improvement in their symptoms, often substantially so.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshops – Posterior Temporal Implant for Head Widening

Sunday, May 14th, 2017

The side of the head is typically seen or described as the area above the ears. It is influenced by a variety of constituent anatomic structures including bone, muscle and skin. Their thicknesses and the ratio of tissue proportions between them all contribute to the flatness or convexity of the side of the head. The side of the head can anatomically be described as the posterior temporal region since this is where the posterior belly of the temporalis muscle runs up over the convex skull shape (temporal and parietal bones) underneath it.

Aesthetic concerns about the shape of the side of the head do exist and I have seen patients feel that either it is too flat (not enough convexity) or is too full or wide. (too much convexity) In cases of a desire for greater width or fullness to the side of the head, the method of augmentation is with a custom posterior temporal implant. (side of the head implant).

Placed either under the fascia on top of the muscle or in a completely submuscular position, the posterior temporal implant can increase the convexity or width of the side of the head above the ears as seen in the frontal view. The typical implant thickness is in the range of 3 to 7mms. When you add up both sides that could be a change of 6 to 15mms. The incisional access for placement of posterior temporal implant is either from a small vertical incision in the temporal scalp above the ear or from an incision behind the ear in the postauricular skin crease. The incision choice is based on implant size and thickness as well as the hairstyle of the patient. The point of incisional access determines whether the implant is placed on either top of the muscle or underneath it.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

Sunday, April 30th, 2017

 

Reduction of prominent cheekbones requires some form of bone reduction. While some may think that shaving or burring can reduce the width of the cheekbones, this is largely an ineffective technique. This is because the only portion of the cheekbone that is accessible for shaving is the most anterior portion right below the eye. This is the anterior or front edge of the zygomatic body which does not have much influence on cheekbone width.

Significant cheekbone reduction requires  moving the arch portion of the zygoma inward. It is the zygomatic arch, or the connection between the zygomatic body and the temple bone that creates cheek width. This is because it is a curved bone structure even though it is a very thin bone of just a few millimeters in thickness. Its natural convex shape creates the widest part of most people’s face.

As a result of its spanning structure, cheekbone reduction surgery requires cutting the front and back end of the arch and moving it inward. The front bony cut is done from inside the mouth and often includes a portion of the zygomatic body . The back or posterior zygomatic arch cut, however, does not include the temporal bone and is done through a small incision in front of the ear at the back of the sideburn (in men) or the preauricular tuft of hair. (in females)

This direct access allows the posterior zygomatic arch to be fully visualized, cut and repositioned with small plate and screws fixation. The location of the dissection is above the path of the frontal branch of the facial nerve so the risk of injury to it is very low.

The usual amount of inward movement of the posterior arch is 5mm to 6mms which usually matches the front end of the osteotomy cut and inward movement.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Chin-Jawline Implant

Saturday, April 29th, 2017

 

Chin augmentation has been done for a long time and many different implant materials and shapes have been used. The most common chin implant used today is that of an extended or anatomic design. Rather than just sitting on the front edge of the chin this contemporary chin implant is anatomic as its side wings blend along and into the lateral jawline to the sides of the chin.

But as useful as the anatomic chin implant is, it does not augment much of the jawline behind it. It remains a front of the lower jaw augmentation method only.

An extension of the anatomic chin implant is what I call a chin-jawline implant. It is a chin implant that has winged extensions that go back all the way along the jawline…stopping just short of the jaw angle area. This creates greater definition of the jawline although not much width due to the thinness of the extensions.

It is inserted just like any chin implant through either a submental or intraoral incision. A submental incision, however, is preferred as it allows a direct line dissection with long instruments back along the jawline. Despite their aesthetic advantages in properly selected patients, the long extensions offer an opportunity for displacement and asymmetry. Small intraoral incisions can be made to check the most posterior portion of the wings go ensure their smooth positioning along the jawline if desired.

The chin-jawline implant offers enhanced bone definition of the lower lateral border of the jawline. It is useful with jaw angle implants to create a total jawline augmentation effect, to improve jawline definition of a lower facelift and to extend the benefits of chin augmentation. It is available in male and female versions that differ in the shape of the chin with the male being more square and the female being rounded,.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Areolar Gynecomastia Reduction

Saturday, April 29th, 2017

 

Male breast enlargement, known as gynecomastia, presents in various manifestations. While once gynecomastia surgery was most commonly done on teenage boys who developed small (or large) breast mounds that did not recede, today’s gynecomastia reductions are different.

Men are much more particular about the appearance of their chests today and are often intolerant of even the smallest protrusions. A flat chest with a nipple that lays flat is what men seek today. This has led to the most common form of gynecomastia that presents as an isolated areolar protrusion or mound. Known as a puffy nipple, the areolar sticks out from the surrounding skin. In some cases it is just the areola that sticks out and in others the protrusion can be seen to extend beyojd the areolar margins.

Areolar gynecomastia reduction is done through an open excision. The firm lump of breast tissue can not usually be removed by liposuction alone. And even if it could that leaves a small but visible scar on the chest wall on each side. Through an inferior areolar incision, the firm breast lump of tissue is carefully removed leaving a certain thickness of tissue under the areola to prevent an inversion deformity. Often the removal of the breast tissue will expose the pectorals muscle fascia.

The size of the breast tissue that has caused the areolar protrusion its usually very deceiving. The visible elevation of the areolar protrusion seen externally is really just the tip off the iceberg of the total breast tissue mass. Anywhere from a quarter to a fifty cent piece diameter of breast tissue is removed and can be more than a centimeter thick.

Areolar gynecomastia reduction can be done under local, IV sedation or general anesthesia depending upon the patient’s preference. Since it does not involve any excision much behind the areolar margins or liposuction elsewhere on the chest, a drain is not used.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Undereye Hollows Implant (Infraorbital-Malar Design)

Thursday, April 20th, 2017

 

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.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Extended Temporal Implant

Wednesday, April 12th, 2017

 

Temporal augmentation is most commonly done by injection techniques using synthetic fillers or fat. While offering a non-surgical approach, their results are often not permanent and the temporal contour may be uneven or asymmetric. More recently developed temporal implants offer an assured volume and a smooth temporal contour result. Placed through a small incision inside the temporal hairline, they are inserted and positioned in the subfascial plane on top of the temporalis muscle.

While the temporal area is not dimensionally complex, it does have two distinct aesthetic zones which are important to distinguish before surgery. In mild to moderate cases of temporal hollowing, the indentation is seen lower right next to the side of the lateral orbital rim and down to the zygomatic arch. This is known as a Zone 1 temporal deficiency, the most common seen, and is treated by a standard temporal implant. When the temporal hollowing is more severe the deficiency will go all the way up the temporal line at the side of the forehead. This upper aesthetic temporal area is known as Zone 2. Some patients refer to Zone 2 as the ‘side of the forehead’ although anatomically it is the upper temporal zone. Its augmentation requires an extended temporal implant that covers both Zones 1 and 2.

The extended temporal implant has a greater vertical length than the standard temporal implant. It provides augmentation from the side of the forehead down to the cheek. It is a complete temporal implant. It is still placed through a small vertical temporal hairline incision. It is also easily adjustable to reduce its vertical length, shape or thickness as needed.

It is of critical importance to preoperatively determine the patient’s temporal augmentation needs by zone to avoid having an inadequate temporal augmentation by using the wrong implant style.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Transpalpebral Brow Bone Reduction

Friday, March 24th, 2017

 

Brow bone reduction surgery reduces the prominence of the lower forehead bone just above the eyes. It is most commonly done in men for large “Neanderthal’ like brow bone protrusions or in male to female transgender facial feminization surgery. Whether it is done using a bone burring method or a more complete osteoplastic bone flap setback technique depends on the thickness of the anterior wall of the frontal sinus and the amount of projection reduction needed.

One aspect of brow bone reduction surgery that can be overlooked is that of the tail of the brow bone. This is uniquely different from the inner half of the brow bone because it is solid bone with no underlying frontal sinus. Whether it needs to be reduced depends on what gender look one is trying to achieve. A more straight brow bone from one side to the other is more consistent with a male with an outward sweep or upwards arch to the tail of the brow bone is perceived as more feminine in appearance.

Trtanspalpebrfal Brow Bone Reduction intraop Dr Barry Eppley IndianapolisWhile the tail of the brow bone should be reduced, if needed, at the time of an open forehead approach from above, it can also be done from ‘below’. Through an upper eyelid incision the outer half of the brow bone can be surgically accessed. Whether this is done for forward projection reduction or inferior bone border elevation depends on the aesthetic goals.

Elevating the lower border of the tail of the brow bone is done to help open up the eyes. By making the vertical distance between the superior and inferior orbital rims longer, the subsequent retraction of the soft tissue back down to the bone can potentially make the eyes look more open. If the forward projection of the elevated brow is also reduced an upward sweep to the tail of the brow can also be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Sliding Genioplasty with Chin Implant

Thursday, March 16th, 2017

 

Chin augmentation can be done through either placing an implant on top of the bone or moving the actual bone forward. Both are valid chin enhancement techniques and each has their own unique advantages and disadvantages. While there are strong surgeon advocates for both techniques, it is important to remember that not every patient is appropriate for either one and what matters for good results is matching the solution to the problem and not surgeon preference or familiarity with either surgical method.

There are rare instances where a sliding genioplasty and a chin implant can be combined. There are two indications for this composite chin augmentation approach. The first one is when the amount of horizontal chin augmentation desired is more than what a sliding genioplasty alone can produce. This would occur when the thickness of the chin bone is less than what the amount of horizontal bone movement that is needed to create the desired effect can be done. The additional horizontal projection is achieved by placing the  needed implant size in front of the moved chin bone.

The second indication for the composite chin augmentation approach is when one desires a different chin shape than that of the natural bone of the sliding genioplasty. This almost is always when one wants a more square chin shape and the natural chin bone is more round. A more square shaped chin implant, even if it is small, is placed in front of the sliding genioplasty. It is vey difficult, if not impossible in many cases, to make the chin bone more square in external appearance.

Sliding Genioplasty with Chin Implant Dr Barry Eppley IndianapolisWhen placing an implant in front of the sliding genioplasty, it is important to realize up front, that there will be some eventual implant settling into the bone. This is not bone erosion but simply the body seeking to relieve the pressure from the pushback of the stretched chin soft tissue pad. It is a natural and self-limiting biologic process.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Tummy Tuck Rib Removal

Wednesday, March 15th, 2017

 

Rib removal is done for a variety of waistline concerns. Such concerns must be divided into anterior and posterior aesthetic waistline issues. The most common perception of the aesthetic benefits of ribs being removed is for horizontal waistline reduction where ribs #10, 11 and 12 may be reduced through a posterior or back approach. `This allows the sides of the waist to fall in at the level of the belly button, contributing to more of an hourglass figure.

But other forms of aesthetic ribcage modification exist. Vertical waist shortness can be caused by a short length between the subcostal rib margins and the hips. The subcostal ribs, made up of the cartilaginous portions of ribs #7,8 and 9, create the downward slope of the ribcage out to the sides. With a low or prominent subcostal rib margin the waistline can be seen as vertically short. In some cases it is not that the subcostal margin is too low but that it may stick out prominentl either on one side or both.

Tummy Tuck Rib Removal Dr Barry Eppley IndianapolisThe subcostal ribs are cartilaginous, thus they are softer than bone and can be effectively reduced by either shaving or complete removal of their prominences. While this can be done through a relatively small skin incision over them, it is also possible to remove them at the same time as as tummy tuck. The tummy tuck has to be of a full variety, but the subcostal rib margins can be accessed by splitting the rectus fascia and muscle from below. (the same anatomic dissection one has to do from the external skin incision)

From this approach ribs #7 and 8 can be separated from their sternal locations and taken back to the bony junction at the sides of the chest wall. Along the way the cartilaginous portions of ribs #9 and 10 can be removed as well.

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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