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Archive for the ‘OR snapshots’ Category

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

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


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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